05080195 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONT,"CTORaINP'U1tMA'CTON
BUILDING ADDRESS: INC PMMITNO05080195
10891 N WOLFE RD
ER'S NAME: PERMIT ISSUE DATE
GGI (GOLDEN GATE INTERIOR) 1982 STONE AVE 08/22/2005
PHONE: SANITARY NO. CONTROL NO.
(408) 280-6500
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i10 LICENSED CONTRACTOR'S DECLARATION Job Description ,p:+^�,
8 I hemby affirm Nat 1 am licensed under provisions of Chapter 9(commencing P'io( •' -
INSecIiOn]OIO)of Division Sof tiro BunnusaM Professions Code.md my license is SIGN--ILLUMI . CHANNEL LETTER '-a,''7'� `L�.uD
a _ LkenlSofome and effec g 3 O
MO.
— Datel'IECTS DECLARTI
I untlersund my plans"I W used u public memis 2005
u
iL Licensed Profcuionsl
G Oat I am exempt ft DECLARATION t• '" `t �' rye VDA Ips
E Iherebymasa .(Sero that 1 1. ,exempt from tite Canbanols Lite Law for Its ,jl A ]) •�yq y(
i o O followingmason.(Section 703 1.5,Business and Rofusiuns Code:Any city or count 'P�fj (, ttira� D tltltl 1 0
O�$ which requires a permit w cormuuek Alw,improw.demolish.or repair any Structure
y.Z> prior to its Usuance,also mquima line applicant for Such Permit w file a Signed nammenl -
�<
that he Is licensed pursuant to the Provisions of the Contractor's Litems Law(Chapter 9 Sq',Ft. Floor Area Valuation
B (commencing with Section 7000)of Division 3 of the Business and Profusions Code)or
— Nat he is eumpt tha efum and the basis for Ne alleged exemption.Any violation of
not on 7031.5
0an Nu30w my
hunappind dollars(SS permit Subjects the APPikant to a civii penalty of �• Occupancy TI pe
❑1,As owner of the prepeny,or my employees with wage u Noir sole compensation,
will do Nrk ansu
the theucwm is nm intanded aoffered forsale(Sec.70M.Bust.
and Professions Cade:The Connxe ora License law does Out apply w an owner of Required Inspections
propeny who builds crlmpraves Nemon,and whodoessuch work himAlfor through his
awn employees,provided that such improvements ane not InteMvl ModfarN for Ala IL
however,the building or improvement is Sold within oro year of completion,the owner.
builder will bve the burden of proving Shat M did not build or Improve for purpose of
ASIA.).
❑1,A Owner of the property,am exclusively contracting with licensed conuacwrn to
construct tiro project(set.71344,Business and Professions code:)The Conmaclols Li-
cense law does not apply an an owner Of property who builds or improves Merton,and
who contracts for Such projects with a comuaver(O licensed pureuant to the Conuacmfe
License Law.
❑Iamexemplundersee .B&PCfm Ntsm Am
Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under malty of perjury one of the following declarations:
❑1 ban and will maintain a Certiftesm of Consent as self-insum for Worker's Compen-
Ation,AS provided for by Section 3700 of the labor Code,for Ne performance of the
work for which this permit u issued.
1 have and will maintain Worker's Compensation Insurance,AS required by Section
J of She Labor Code.for the Performance of the work for which this permit is issued.
My Worker's Compensation Ing nonce am.a and Policy number ane:
Cartier. M Poliry No.:�13L ; L�
CERTIFICATE OF FJIFMPIION FROM W RO KERS'
COMPENSATION INSURANCE
masumion reed not W completed ifde permit is Ionone hundred dollars(SIM)
or less)
I anify,that in the Performance of tie work for which Shia permit is leaned.I shall nu
employ any person in any manner So u m become subject to Ne Workul Compensation
haws of California.Data,
Applicants
NOTICE TO APPLICANT:IL aft,mating Ihis Omiliam of Exemption.you should
become object m the wohcr's Compensation provisions of Me Labor Code,you mut
OQ foMwidt amply with such provisions w this permit Nall M demand!revoked.
'z0 CONSTRUCTION LENDING AGENCY
F•i 4 Hereby or..that thertkaeonswctinn lending Manny fu Ne perfarmana of
a 7 the work for which this permit is issued(Sec.3097,Civ,C.)
10 Lender's Name
=z Lender's Address
U 0 1 canify that 1 have mad this application and sum that the show InfmmatiOn IS
IL.!' cornett I agree w comply with all city and county ominanas and SUM lows misting in
0 SV' Wilding construction,and hereby auNonu mpmxnutlwa of this city N now upon the
W above-mentlonsd property far Inspection purposes
O. (We)agree w vow,indemnify and keep hanrnmAS the City of Cupertino against
y 11
liabilities,judgments,cuss And expenses;which may in anyway accrue against Aid Cly
ID "
in consequence of dm granting of this Permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs 12/-7HAZA
Signature of AppliuHAZARDam �I
HAZARDOUS MATERIALS DISCLOSURE •)Ie Of ROOF
WIII tiro Applicant or forum Wilding oceupanl swm orhandlc haYLdova mammal
40ned by the Cupertino Municipal Code.Chapmr 9.13,And the Health and Safety
e.section 75532a)7
❑Yu $No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant Or future building occupant use equipment or dcvlas which If a roof is installed without first obtaining an inspection,I agree to remove
cmitbaemoa,air antsmimnts AS,unlined bythe Day Arm Air Quality Managcment all new materials for inspection.
District?
0 y Nu
haw ran the taamoumaterials
reqientunder Chapter e Califon
nu Health&Safety Code,Sections 1550 25334.1 understand that ifthe buildin
,yt�
does An,cuimnlly haw a tenant.Nn It As my responsibility N nmtifY circ oecupani of Ne �/r� .✓.�
req I ts hichmu metpnorwiuuanccofo Ccnifiamof a Signatur Of p licant Date
Ownerunulho udagcnt - Dam All roof coverings to be Class O$u Or better