08100046 CITY OF CUPERTINO
BUILDING DIVISION PE SCO I29LC�"TOR INFURMATI� I „
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PERMIT NO.
BUILDING1VT8EsCANYON OAK WAY WALTER M. SPRINGS 08100046
Sh"ERL'S NAME:
PERMIT SUE DATE
IF STEVE YOSHIMOTO 370 INDUSTRIAL ROAD STE J 10/08/2008
PHONE: SANITARY NO. CONTROL NO.
(650) 592-2922
ARCHRECTIENGINEER BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
tato LICENSED CONTRACTOR'S DECLARATION Ib Description
1 hereby affirm Nat 1 nOesCTIP
m licensed under provisions of Chapter 9(commencing
ZZ with sordes'llsU)ofDiv;uonsofN�Busircvand itkoiinaCult,uwmyRmnsu RMV&RPLC SHWR IN MSTR BTH, FNSH 2 UNFNSHD AREAS
a?a infull farce and effort. 0)30003
�qz LKcmc am Lic.g INTO CLSETS (BTH2OSQ&98SQOTHR)
F Data Cemnfmar PN
p A citri-EcTSDECLARA Imo—
uSl 1 understand my plans aNll he used as public records
eat; LicrateO professional
3 OWNER-BUILDER DECLARATION
a�n o I Wmby aRm Nat 11. esusin Item Nc easi..Cos License city
O for IW
i O O which
meson.(Saito]031.5,Business and ere.dem ns Cade:My city tcounty
$ whorl,requires issuance.emso re cmnwct,altars improv,h PC=iah,u e a sig ed mentum
pritrmitaensed afmmquiros the ilio o for such torileLaw(tatemem
pp < Nsshe uhcevedpmsuanu0=aDi%isim3of tum nr'e License law(Chaptu9 Sq.Fl.Floor Area C Valuation
Y�$ thal hencingwish Satious and WDiviis for casteeged euandon.My viCade)or 920000
Nat ca u wombs IMaefmm and the bass for Lha alleged eavnpdas My l Penaom or
salon thesfby atry,hundred
(or,pennil sub$w Ihe,ppliantm acivil penalty of Number Occupancy Type
oat mete Nan fie hmnama dellen(swo) 34260003 '�l�
1,u owner of the amputy,or my employees wish wages as theb mole sempemdon,
willW the work.and use structure Is not intended or artucd for sale(Sec.7W,Businw Required Inspections
and Professions Coda The Contractors Liao Law does net apply m an owner or q P
property who buildsor;aproses,thereon.andwhodocs such wort himsclrorthrough his
awn cmploym,provided Nat such Impmvementa are wt intended consisted for sale H.
however,Ne Wilding or improvement is sold within..Year of cunPledon.Neave- .
Wilda will have the burden of proving Nat he did wt Wild or impmw for purpose of
sale.).
❑1,as owner of dte property.am exclusively contracting with licensed eco..to .
co suuct the project(Sea 71)e4,Businm and Professions Cade:)The CoMoVen s LL
.Lew does out apply no am twos of property who Wilds m;mpmw Nertan.and
who contracts for such pmjec s with aconvxtor(s)licensed pursuant m the Contactors
Lice”Law.
❑lamuereptuntler See .B&PCrordismsson
e Date
WORKER'S COMPENSATION DECLARATION
I hereby arm under Penalty d pcsjury eve of the folhrviag Acclaadons
❑I have and will maintains Cion 37 te of Comm mCast.furefor Waheru Compa-
adon, r which this
for i section 3]001(the IsWr Code,for the pedomunce of she
work for which Nis pcsmit u issucd. .
❑I have and will maintain Workers Compensation InWnnce.as required by Section
3WK).f the labsr Code,for use perfamanceafthe work forwhich Nis permit It issued '
My .JWort c,r
Coatopeensation Insurance carrier and Policy number are:
Carrier. I 4r6� "P Policy No.: 4511-O OO L4 O�-�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this secdm need tet he canpleted lithe postal,Is Tor eoe hundred dollars(f 100)
or las)
I certify Nat in the performance of the work for which this permit is used.l shall net
croploy any person in any manoerro as an became subject to the Workeri Cempensatian
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this CcniOo¢of Exemption.yen abouW
become subject to use Workers Compensation provisions of Ne Ltaba Code.you mm
z forthwith comply with such provisions or this permit dull W deemed mated.
z^ CONSTRUCTION LENDING AGENCY
[err 1herehy.M.Nat Nem I,a conswctinn lending agmaY for thepurforroanceof
Q:
the work for which this permit H issued(Sec.3097,Civ.C.)
W�Q
under'
s None ,
z Lenders Address
U 0 1 certify that I have rod Nis appliatitn antistatic Nat dta aWve information u
I,U cortaL I agree m comply with all city and county nNInNRt and state laws relating m
0 Wilding construction.and hereby authorize representatives of this city to onto upon Ne
W aWw-mcntionad property for inspection purposes-
(We)
urposes(We)agree w.uw.Indemnify and temp hasmlm the City of Cupertino against
Z in COiticsjudgmenteerasing eapemswhieh maytaany t+',Yamuc,g,lost slid cry
U z A APPLICANT
of the UNDERSTANDS
of Nu permit
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Lf ,ei2e„ni /0-8-08 Re-roofs
Signature of AppllanPContrutaz Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will dta applicants or future Wilding oecupant store orhavdk haerratua marerisi
deflncd by Ifo Cupertino Municipal Code.Chapter 9.13.and use,HesIN and Safety
.Seedan 25532(,)] All roofs shall be inspected prior to any roofing material being installed.
]Yes )01 No
Will de,,pplican,or future Wilding occupant use equipment or dentes which If a roof is installed without first obtaining an inspection,I agree to remove
emit hasndow airconuminanu a de0oed by the Bay Ara Air Quality Mmgernenl all new materials for inspection.
District?
❑Yes IFW
I have cowl the hazvdau materials requimmenu under Chapter 6.95 of the Califor-
niaHealth&SafetyCode,Son.25505,25533 and 25534.1 understand that ifft Wilding
does not cerrendy have a lomat.use.It umy temponaihility m Mildly ft Oss pavt Of the
reyairemcnta which mesa be met l.intaimst,ad,e or.cwgc,te oraap.ay.adl Signature of Applicant Date
�S All roof coverings to be Class';.”or better
Owner or .,ho...dagent Dam