06070209 (2) CITY OF CUPERTINO -* A
BUILDING DIVISION PERMIT CONTR lbA', INF
0 ORMATION
BUILDING ADDRESS: MC SHANE THOMAS J AND BIR IrT06070209
21760 STEVENS
R'S NAME: PERMIT ISSUE DATE
O NE
MC SHANE THOMAS J AND BIRU A S
E:
SANITARYNO. CONTROLNO.
BUILDING PERMIT INFO
ARCHTECT/ENGINEEA: - BLDG ELECT PLUMB MECH
0 0 0 0
;00 LICENSED CONTRACTOR'S DECLARATION lob Description
I hcmby grim that I am licemed under provisions of Cannot,9(commencing P
with ScCum 7")ofDiviaion J a(oe Businessand Professions Codc,and my liccuu is
„ immf(orneand.ff.L y g REVISION TO ORIGINAL 06030165
z License ass Lie.g
•moo Dam •y •�Contncmr Car ✓. BUILDING A CONTROL ROOM FOR T-MOBILE ADD FLOOR
ARCHTTECrSDEC�< IUMersundmyplmssh.11Wusedu b1ccmccotb JOIST AND A HARD CEILING
IaU
Licensed Pmfcssionel
OWNER-exempt Fmm ulm Com ON
eto
I hereby alum Not 1 1. exempt from Ne Canlns Co :Any c Law for oc
ISIO following moon.(Schon 7117 L5,Business arld .,de Professions Code:Any city or county
I
�i which rcqusu n e.AIS m c ims the aper.impmsu,h Pamir
amu t ri repair any suumure
=2a butIm ,lienedValrem 1.rex provision M1(of Connector'sLcensee A Law atlkmenl
C (commencing licensed Valorem 3ofthenUsiness nxcnuhw(Code)or Sq. F[. Floor Area Valuation
l�
(commencing with Section 7")of DivisionJof the Business and Professions Code)or $75000
$ that he is cumin therefrom and the basis for Ne allcgcd exemption.Any violation of
Section 703 LS by any applicant for a permit subjects due appiitmL10 a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(M).
1,az loner of the pmpeny,or my employcu with wage w their sale compensadnn.
will do use work.And she awcwmianmmandedaroffered formic(Sec.7oaa.Business Required Inspections
and Pmfassom Cade:The ConuaemYs Lion law does nor apply m e an owner of 9 P
pmpcny who wildsorimprosu themen,and whodoessuchwurk him.Wf m Waugh his
Own employee,provided that improvements are not intended or offered forsatc.IL
however,the building or'unpmsemem is sold withi...year of ampletioo,the owner- �
builder will have the burden of pmving Nat Im did not build or improve fur purpose of
&C 1,az owtmr a the prepenY•and ueludvely eonvaning with licensed comacbm to
construct the pmjea(Sec.7004.Business and Professions Code:)The Contractor's Li. (`
Cense Law does nut apply to an...,al property who Wild.of Improve W Ron.Nd, V `
who contracts for such projects with a antractat(s)(icer sed p rrwam to the Contractor's
Licence law. , ,J
❑ 1 am exempt under Sec. ,B A P C for WT mason \
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under panalaY of perjury one of the following declarations:
❑1 have and will maintain a Cenificare of Consent to elf-insum for WorkeesCmnpcn-
amion,as provided for by Scomm 3700 of the Labor Cade,for Ne petfamance of the
were for which this Permit is ommi.
&C I have and will maintain Worker's Compensation Insurance,as mquimd by Section
3700 of the labor Codc•far due per(omana of the wart for which dust Permit is issued. '
My Workcfei(Compensation puunu�x/lcarrier and Policy number ane:
Carrier:l/ R•�! ✓f'•I./ PolicyNo.: jWf2o t
COMPENSATION _
CE0.TIFl OMPS EMPf10NFRERS'
CNSATION INSURANAN CE ,
(Thu section need not be complCKd if the Permit is form=hundred dorms($ICO)
or lest
1 ccnify thm in due peofomana of or.work for which this lank is issued.1 shall not
employ any person in any manner An as N Wmme subject to lk Workers'Compensation
laws of California.Data
Applicant
NOTICE TO APPLICANT.If,after making Nu Certificate of Exemption,you should
becom subject an dm Worker's Compcmation pmvinions of due later Cade.you mut
.,O forthwith comply with such provisims or this Pcmi $hall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
(-a IhComy AM=dust thane is a emaromAln lending agency for Ne.performance of
7. due work for which this pamit At issued(Sec.3097,Cl,C.)
GQ Lenders Name
.7 rZ Lmdeh Add.
V 1 ccnify that I have read this application and sum that the above infomatiun is
ly comet.I agree to comply with all city and county ordinance and sum laws relating m
J V building construction,and hemby authorrae represcntatives of this city to enter upon the
red
above-Mentioned
dgmpmp esttLy faninspection pturlsowhich may
FG (we.)agme to saw.indemnily and kceP hamlet due City of Cupcnino againa
'h in,.iucs,judgmc do casts and Or%is expenses which may in anyway ettm against Said City
C)z incanuqucnce of thegranting a(Nis permit. /a—/�'-O�
APPLICA DERST SAND WILL COMPLY WITH All.NON-POINT Issued by: Date ('J/I
SOUR E VLA S. .
_ W _ .�_ '/Y-o/ Re-roofs
Signaum,afAppliandContrzclor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant alone or handle ha odow macrial
as defined by due Cupertino Municipal Cade.Chapter 9.12,aM the Health and Safety
.Section 255320)7
&Coca CTN. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hmardouT air contaminants az dc0ncd by the Bay Arca Air Quality Managcmenl all new materials for inspection.
Modern
❑Yes elf.
1 have Rad the hmardae materials Rquimmnrs under Chapmr 6.95o(Nc Glifor
nixH.10&1fetyCo .Sc6wu25505,25533and25534.IwNenarod Natifdc building
door not c redy h mount,our it is my responsibility nouly du occupant of theRgai tsw�u mouN
xtb`emet priormiaxnancemaccrdRcamofecupancy. Signature of Applicant Date
-117-.91 All roof coverings to be Class"13 or better
Owner ar auth ub,ed agent Gum