08120013 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CO1TItAC TORII!TI URNIATION �•
BUILDING ADDRESS: PERMIT NO.
10430 S DE ANZA RTWD STF 210 TBD — TO BE DETERMINED— 08120011
ER'S NAME: - PERMIT ISSUE DATE
PHO E: A CONTROL NO.
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u0ij LICENSED CONTRACIDR'S DECLARATION -
C 1 hereby affirm Nal I am locoed under provi inns,of Chapter 9(commencing lob Description
L+
with Section TOW)of Division 3 of the Business Professions Code,and my Became is
noH mIU all ` REINFORCE CONCRETE STAIRS W/HANDRAIL, REINFORCE
DM i License Clan
Ct, Da¢ �) S cnvxror I' CONCRETE CURB RAMP FOR ACCESSBLTY.
ARCHITECTS DECLARATION
I uMcrvand my pins shall a used u public records
D.Q
g C Licensed Pmlatir..I
c OWNER-BUILDER DECLARATION
a� E I h=mhy affirm Nat I am exempt firm the Contractors License Law for 1W
C p e) following maven.(Section 1031-5.Business and Profawas Code:Any city or county
$pi which mquiraa a permit to immortal,atter.improve.demolish.or report any summers
prior a its iuuancc.also mquitn the applicant fatsuch permit to file a signed statement
< tMlheulicenttdPursnnuoNaprovisBonofthe Conuulor'sUccomLaw(Chopmr9 Sq.FC Floor Area Valuation
y�$ (commencing with Section 7000)of Division 3 of Ne Businammd Pmrossions Cook)or 15000
Q Nat he u exempt Ncrefrom and the bur for Ne alleged exemption.Any violation of
Section 70313 by:try applinnt for a permit subjcets Nc aPPIuxaL to a civil penalty of APN Number Occupancy Type
ml more than It.hundred dollars($M 36940039 .210
L,as Owner of the property,Or my uoployvA with wage u then sok compensation,
will do the work.and the structure is net intended Or collared for sak(Sac.700,Business Required Inspections
and Professions Code:The Conuicwrs License Law does tee nst apply e an owner of 9 P
property who builds orimpmves Nermn,and who doessuch workhimself or through his
own emplo m a,provided that such impmwmmts are not amended oroffered for sale.If.
however,the building or impmwmem Is sold within one year of completion,the owner.
builder will have Ne WNce of proving that he did tet build or impmw for purpose of
sale.).
❑1,as owner of the property w exclusively mourn:trig with licensed mm x1W 5 e
construct the project(Sec.7014.Brennan and Pmfesion Code:)M Contactors U-
tonne Law docs not apply 1n an owner of property who builds or impmvu Merton,and.
who contracts for such projects with a contractor(s)licensed p ammant to the Contractors
License law.
❑lamexeropiunder See .B&PCfor Numason
ar Data
WORKERS COMPENSATION DECLARATION
I hereby a(frm under penally of perjury One,of the following declaration:
O 1 ham and will cadmium a Certificate of Consent to seIrArop m for Workers Compete
satire.as provided for by Section 37W of the,Labor Code.for the Performance of the
wort for which this pmmit is issued.
1 have and will maintain Worlm's Compensation Insurance,as mquirtd by Section
37W of the labor Code,for the performance of the work for which this Purities issued.
My Workers Compensation ran
d li num am:
Carver.n T Fl..� rJ✓io.-o/'l pa a.:
CERTIFIC OMPE SATIONII FROM WORKERS'
COMPENSATION INSURANCE
(Danced.nerA Out be compkmd if Ne pewit is forme hundred dollar($100)
or less)
I certify that in she performance of the work for which this Permit is issued.1 shall not
employ any person in my mmrmrso u in become subject to ins Wrrkcn''Comp ommon
Laws of California.Date
Applieanr
NOTICE TO APPLICANT:IL after making Nu Corollate of Exemption.you should
become subject in the Worker'.Compensation provisions of the labor Cade,you mut
.J O forthwith comply with such provision or Nu permit shall be dcemrevoked,
oked.
z"" CONSfRUCnON LENDING AGENCY
[rte I hereby alarm that Nem is a conwclinn kndingageixy for the psurforman¢uf
FL i we work for which Or Permit is issued(Sec.309'1,Civ.C.)
sanders Name ,
z Landers Address
U O I certify that I have Ind this application and sone Nat Ne above information u
LI. E coma.I agree to comply with all city and county ordinances and sate laws mating to
C) building convection,and hereby authorim mpreseniuva or Nu city to enter upon the
[21 alrow-mendond property for inspection purposes
(„� 1 (We)agree to save,indemnify and keep brimless de City of Cupertino against
h liabilitiesjudgments,casts and exileam which may in my way auntie against mid City
U,Z in eonox itemm of the granting of this permit.
^ APPLICANT U DERSfANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
RC
SOUE R� A 1�
// Re-roofs
Signature of ApplicaruContrx Dam r—
HAZARD USMATERIAISDISCLOSURE Type of Roof
Will the applicant rr future Wilding oceupmt sera orhamik hanrdou material
as defined by six Cupertino Mu opal Code.Chapter 9.13,and the HW N and Safety
.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
i]Yn o
Will the applicant err fuWilding occupant use equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
..it ha ani air cmumirun dcOxd by Ne Say Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have mad the hazardous materials recruitments under Chmmr6.95 ofthe Califor-
niaHealth&SafctyCode,Section 25505,25533 am125534.1 umkrssnd Nnifthe Wilding
does tet currcndy ace a tinam,that it is my responsibility to notify dm mcuPant Or the
require muv be 'or in iss.nia CatiOnm of DierPmay 'Signature Of Applicant Date
/16/74 ng'
Owner est tet rdved:g=uns ram All roof coverings to be Class'1?."or better