05020009 (2) CITY OF CUPERTINO Ff ;*aog�- . t )• .a
BUILDING DIVISION PERMIT "Co TNroP'ORMATIO
BUILDING ADDRESS: CIVITAF CORP PERMIT N'65020009
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY HIT NO.
(408) 39q-4949
ARCHITISCrIENGINEER: BUILDING PERMIT INFO
z ELDG ta ELECTO PLUMBO MECH
1�
LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm thns m 1 am limmo d under provisioof Chapter 9(commencing
¢ IN Suwon 7000)orDivision 3 of the,Businruand ProfessionsCode,and my license m
'^< in full fume and effect.
Sq— License Llo. REVISION--NEW WATER SYSTEM
Data
ARCHI'IECfSushomr-L ION NO NEW PERMIT ISSUED/ORIG. #01080098
I uedereand my plana Mall he used As public recmdt
3�
,`ata
Licensed Professional
OWNER-BUILDER exempt
DECLARATION
E a I hereby Matc affirm that 1 am eecmpl tram due CanuanCo License Law for the
Ea O (allowing mess a emit t ]comment,
t,Business and w.de funs Crum:Any city or mums
$ which requires•pewit m coral do sites hnprow,deem it t ri e a sig and nnmmro
F-Z'S' prior bits censedc,Alan rtqulme thcappliS Of for Cork pewr&License
Atstemom
{t5q� Nnheuamcd pursuantmthe of Diriwu Of lk Conuanessai x�law(Chapmr9 Sq.F[.Floor Area Vd{U$li(]M 00
S ue
(commencing1. xemt Section 71110)ofDivaionr of the jeincumd Professions Cade)or Y 7VV
WI he m exempt thuefrom and the basis for Ne alleged exempdm.MY vlolaUon of
Section 7031.5 by any Applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred do1Ws($500).
01,nownerolthe propeny,urmy emplayrn withwW numbaaleeompennuan, 36603061 . 00
will do the work,and the ctmcture Is nuthromded araaertd forde(Sm.7044,Business Required Inspections
and ProfeWm oCade:The Con Mems License caw does veel apply to an owner of q P
property who bu Ilds or improves thereon,ave who dues such work himsel f or through his
own employees,provided that such impro,ement,art vol Intended molfrsed for We It,
however,Ne building or improvement is sold within am year of completion.the owner.
builder will have the buNut of proving duet he did nm build or Improve for purpose of
ate.).
❑1.As Owner of the property am exclusively contracting with licensed mnbacmn In ^�
construct the pmjon(Sec.7044,Bmines5 and Professions Code:)The Cwtncmis Li-
mese Isw does not apply in an owner of properly who builds or improves Merton,and
who contracts for such projects with aeonuaemr(0 licensed purwam to the Commicoes \ /\
License Law. J
❑I am exempl under Sx •B&PC for Nis reason \\
Owner Date
WORKERS COMPENSATION DECLARATION '
I hemby affirm under penalty of perjury One of the following dMantious:
ve end will malnW n a Cer1ificom ofConsem m self-insure for WOult Campeo-
n,As provided fm by Section 37M of the Labor Code,for the Performan¢of the
work for which this permit is issued.
❑1 have and will maintain Worktfs Compenudan Insurance.as required by Secdon
37W of the Labor Code,for the puformanx,of the work forwhich this permit is inion.
My Worker's Com matiw Insunna artier end Policy number
Cartier: Polley Na.; D
CERTIFICA O P.KEMFION nOM WORKERS'
COMPENSATION INSURANCE
(This section neon not becompleted if the permit Is two=hundred dollar(SIM)
or less.)
I unify that in Ne parformamx of the work for which this Permit is issued,I Mall nue
employ any person in any manner so As to become subject to ted Wortrn''CorepensWon
I..of California.Date
Applicant
NOTICE TO APPLICANT.If.after making this Ccnincam or Exemption,you Mould
become subject in the Workeh Compensation provisions of the LAW Code,you most
.,O foMm with comply with such pravmioor this permit shall bdeemmv
e ed nked.
Z`
CONSTRUCTION LENDING AGENCY
[-n IMreby aRml the Vert is a cunanuctinn lending agency for the performance of
pL> the work for which this permit is issued(Sec.3M.Civ.C.)
0 Lender's Name
i7. z Londera Address
U0 I certify that,l have mad this application and rete that the above infotmadun is
Iy mrrem l agree to comply with all city and county ordinances and sum laws misting m
building hereby awhorinmoses, lives of this city reenter upon No
W ahovcmcwomd propene far imnify an purposes.
py, (WO)egret m outs Indemnify end tree ay In m the City of Cupertino against
VI liabilinconsequence
Of mcesuandofpcmnmit. may In any way same against said City q X14
(,7 A PLICANT of Ne RSTA gof this permit �. L VV
F7 APPLICANT UNDERSTANDS AND WILL COMPLY w11H ALL NON-POINT Issued by;9102� Date
• EOULATONS.
Re-roofs
Sir,lanfc,or Appliom/Canuuuur Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant Atom or handle havaNuos material
as dented by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Coke.Scednn zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya $Na
Will Nc applicant or forum building amupam tax equipment ar dcviees which If a roof is installed without first obtaining an inspection,I agree to remove
hayvdnua air contaminants a defined by the Bay AMA Air Quality Management all new materials for inspection.
in7 -� ,�fy
❑Yes IYINu -
I have medthe hvaN--nu""s��mamru4 rtquimmtmsunderCMpxr6.93 ofthe Califor-
niaHealth&SafelyCode,Som.25505,25533 and 25534.Iundcn and thalifuse building
does not comedy have•¢funs,that It b my responsibility m notify de occupant of the
myvi hlehmunbOmetpriormin enfacmAnateafaapanry. Signature of Applicant Dale
All roof coverings to be Class "B"or better
Ow r.um.MMd.j;,m Dom