08090098 CITY OF CUPERTINOga;a*r
BUILDING DIVISION PERNUTCONTRACTQR IIV"k'ORNI' 'U
BUILDING ADDRESS: PERMIT N0.
10500 N DE AN7A RTATQ SOUTH BA
R'S NAME: INC PERMfr ISSUE DATE
PHONE:
A O. CONTROL NO.
(408) 379-5500
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
fop LICENSED CONTRACTOR'S DECLARATION lob Description
1 normal affirm that i am Ikcneed under provisions of Grainer 9(rnmmencing P
with Section 70(Io)of Div a 3 of du Bounce,and Profcssldm Code,and my lice s,u
"o'erIn full fares d.ff— - y 1 ST FLOOR REMODEL 3400 SQ FT OF AUDITORIUM,
:,� OmeT CCoa1
onra �2c. LAPPET, SCRREN WALL, DOORS, ELECTRICAL &
ARCHITECTS DECLARATION
I understand my plans shall W used as public metals WHEELCHAIR LIFT INCLUDES STRUCTURAL
Jm,U
lta� Licensed professional
OWNER-BUILDER DECLARATION
ny I hamby affil that I an camp,from the Contactors License law for the
`p O following reamn.(Secd
an 703 1.5,Business and Pmfessm.Cade:Any city or county
S which require a permit to costruct,alcor,improve,demodim.Or repair any stmctum
hnor 0 its inumec,also require Ne applicmt for such permit to file a signed sufement
at he u licensed normal to the provisions of the Conuaues Maxum Law(Chapmr9 Sq.Ft. Floor Area Valuation
yl-S (commencing with Section 7000)N Division 3 of the Business and Prufoodom Code)or
r3— also he is eaemp tMmfrom ad 0c basis fur the alleged exemption My violation of 52000000
Section 70713 by my appliant fog a permit subjects the appellate,at a civil Penalty of APN Number Occupancy Type
at more d m ffve hundred dallua(S3(3). 31622017 . 0 0
1,u owner of the popery,a my employee with wages u aluir sok compemdon,
willtiothework.adthesmciumisnoti.¢.&d..ffe draeshe(See.704,.Business Required Inspections
aad Professions Cade ua
Tie Conciara I.iermanner Law does not apply n owr of q P
property who builds o improve thereon,and who does such work nimulf o thmugn his
howemrownemployee,poWdrri Natcocaimprowmau tae not ourofc moQuW me mwbm.
Wilder.citebuildingmodao pmatiscoldwithinate Wear ofcompletion,the purpose
of
Wilder will have the burden of proving that he did cot Wild o improve for Purpue of '
alcJ.
(]1,as owner of the property am eulusively contracting with licensed contra ors to
eonaWe doe project(Sec 70U,BLLunea sed Pinfesoe Code:)The Connor's U.
certse Taw does am apply to a owner of property who Wilds or improve thecon.and,
who contracts for sures projects with a conuanor(s)licensed partial to the Connors
License Law.
lam exemptundersee. ,B k PC for the won
Das
or WORKERS COMPENSATION DECLARATION
1 bereby affirm under Penalty of perjury one of the fullewing declaratinrae
❑1 hsve and will maintain•CaNOcam of Cosem m self-inurefa Wokera Compem
talion u provided far by Section 7700 of the Labor Code,for elm pniarmatt¢of the
work for which this permit is issued.
1 have and will maintain Wommes Comp rt.tion lasurmce,u required by Section
3700 of thv Laaar Code,for the performance of du work for which this Permit is issued.
My Work s Compensation Insusmx curie and Policy number tae:
carrier. IAl}IQ 4rgL Palky No.: CwOtoftM'_f
FlGTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seNen tact at be completed if ono permit Is fear handed!do1Ws($100)
or les.)
1 certify that in Ne performance ser Out work for which this permh is issued.l shall not
employ anyperan in any manner m at in became subject to the Workers'Compewtion
Laws of California.Dau
Applicat
NOTICE TO APPLICANT,If.after making this Certificate of Emmption,you should
become subject te the Work s Common tis provisions of the Labor Code,you muss
O forthwith comply with such provialde o this permit shall be devoted rooked.
„zr71 CONSTRUCTION LENDING AGENCY
[--r 1 Array sfffem that them is a conxvucua lending agency far the arformsruc of
0 > Ota wort fa,which this Permit is iuod(Sec.309'1.Civ.C)
W25LaticesName
Latices z Ies Addw
U Q I.,Ofy the I have mad Nis application and mute that Ne shave information is
LL, ^. correct.l agree to comply with all city and county ordinances and sum laws miming to
0 rV' Wilding construction.and hereby sumonne mpemnudves of this city In enurupnn Nc
r shave-mentioned property for inspection purposes.
f+ 6,
(Wo)agree to an.indemnify ad kap harmless the City of Cupertino agaiw
N Iialdlide,ndgmenu.casu end expenes which may in my wayacaxagunst aid City
(.j z APP CA UNDERSTANDArtsP��WILL COMPLY WITH ALL NON POINT Issued by: Date'
SO RCER LATIONS. I/ p I Iy �G
Y..LLR/'—" G Re-roofs --
Signaue of AppliaHAZA Due
HAZARDOUS MATERIALS DISranorh dl Type of Roof
Willy i appliant o forum Wilding Conte.
Cap comm or handle Health ad
Med io Ihv Cupertino Municipal Cabe.Chapter 9.@.coal the Health coal Sa(dy
..section 25532(a)7
[Dy. VIN. All roofs shall be inspected prior to any roofing material being installed.
"o
Will tic apphamet or future Wilding aeupant rase cquipma,or&Har which If a roof is installed without first obtaining an inspection,I agree to remove
emit Itsmal a air conuminats u de0ned by the Bay Arta Air Quality Msnagemen, all new materials for inspection.
District? v1''
❑Ye esu }
1 have read thehauNeu materials me ui.nmms undo&pbm G95 of the califm.
nu He1N my Cade,SecJou 25.513.25533 mdU534.I understand!Ne ifdc Withng
don courally Ww a torn.the I my responsibility te notify aasupanl of do
mqui mcnuwhihmuatnomct or iaWaaafaccrtieamor p Signature of Applicant Date
M" n ,
Owner amboiadagent bac All roof coverings to be Class'?{"or better