08120090 BUILDING DIVISION PERMIT t�CONTI2FiCTOR INFORMATION
9xay,aSa°c.1`�r �9..'ab4R x4a'�cSw R,.= �;k�.-$�3tia
BUILDING ADDRESS: PERMIT NO.
20510 TOWN CENTER LN PROVISION DEVELOPMENT,
ER's NAME: PERMIT ISSUE DATE
PHONE: A CONTROL NO.
(408) 245-0991
ARCHITECT/ENGINEER: BUILDING PERMR INFO
BLDG ELECT PLUMB MECH
0 0
X00 LICENSEDCONTRACIOWS DECLARATION Job Description
,wC 1 hmcby sMon that 1.lived under providmu or Chapter 9(commencing p
iW wish Sccum7000)af DiHsion3n/d,eB,sti,.<.asM Profusiv�fad9.sand my Bc"is
?ma. in run fotcc am effcc. /(nIl'' I/ TEMP PERMIT FOR COMM'L TI FOR NEW DENTAL OFC;ORIG
a a Z Liccmse Class Uc.g
�� Dan Cmoranor PERMIT #08100189- NO INSPECTIONS AFTR 1/12/08
ARCHIIECTS DECLAFLATTON
wI undcrsund my plans shall he uud as public records
U
C In Liccmd Pmfcssional
5 OWNER-BUILDER DECLARATION
I botchy affirm that I am exempt from the Caotractofs License Law for the
00 following muoo.(Sadao 703 1.5,Business and Pmfmdons Code:Any city or county
e$_ which smuina a permit to commons.slur.Widow.demolish.at mpair any stmetum
'szy prior to its issuance.also esquires thcapplicant for such permit to flit.signed suumcnt
< Nasheuliccmpm
dpu..(tothemvisioofNcContractor' nu
Ucehw(Clupur9 Sq.FL Floor Area Valuation
1m 0 (commencing with Sccdon 7000)of Division J ofthe Businessand Profusions Cade)or
y that he u exmther
pt therefrom and the Wds for the alleged u
allegemptim.Any violation of $156000
Section 1031.5 by arty,applicant fm a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
mBhmMm
est mom than K d dollars(3500). 35908018 .RC p y YP
I,u owner of me property,ar my esoployaa with wages as their sok compensation,
will do the stock and theswcu¢is not inuMed or offered for$ala(Sm.7W,Broin m
and Pmfessinm Cade:The Co urumfa Liam Law does out apply in an owner or Required Inspections
property who builds or improve Hereon,and who dassuch work himself or through his
own employees,provided that such improvcmenn ere not intended oroRemd fusak.If,
however,the building or improvement is said within om year of completion,Out owmr-
builder will have the burden of proving that M did not build or improve for PURm of
sum).
(J 1.as so mf of the propcny am caclusively contracting with licastsed contractors to
contract the project(Sec.1064.Business and Pofessiom Code)The Cmmcsafs U-
come Law does oro apply to an owner of property who builds of improves Neeson,and,
who comers for such projeaf witha cmusnon(s)licensed purses.to the Caisson,
Liam Law.
Q lumew.,nudder See .B&PCforthismason
Dau
WORKER'S COMPENSATION DECLARATION
1 hcmby salon under pemlty of perjury ane of the following decimadom:
❑I bare and will mainuin a C.rdfIau of Consent to sett--insum for Workces Compen-
sation,u provided for by Smoon 37M of the labor Code,for the performance of thc
work for which this permi,is issued.
❑1 hale and will maintain Wo tan'.Campematimn Insurance.u raquimd by Section
3100 ofilm Labor Code,for the pcdo...of the work for which the perm,is issuW.
My Workef Cyo a,mmgaatim.W urana artier and Policy number am:
Cartier. I/�I Q N I� Policy No.: �-- SI �8
C Fl OF EXEMPTION FROMwORKFRS
COMPENSATION INSURANCE
(1Tu section nod not be complcud if the perosit is forme hundmd dollars($I00)
or lens)
I Coolly Not in she performance of the work for which Nis permit or issued,l shall not
employ any possan in any manncrar as to become subject to the Workers'Comperumon
Laws ar California.Dau
Applicant
NOTICE TO APPLICANT.IL altar making thin Certificate of Exemption,you should
income subject to the WorkCs Compensation provisions of the labor Code,you must
.,O forthwith pron m Nu comply with such visiopermit shall le deemed rswked.
Z '-' CONSTRUCTION LENDING AGENCY
(—sem Ihcrcby affirm the dem u a consumtorn landing agencyfar the perfmmas,m of
E
> the woM1 for which this Knout is issued(sec 309'1,Civ.C.)
1 0 lees Name .
5 Z L<ndefs Address
U C) I certify Nu 1 have mad this applicaion and soon that the about information is '
U, ca mm I agom in comply with all city and county ordimnces and sun laws misting to
.0 C.; building construction,and hemby mmusim mpmsuattioes of this city m cnscru e
U above-mentioned property for impccdon purpms
(We)agrte to save,indemn ly and kap h dy sf Cupmino against
mL.m fag liabilitim,fudgmcns,costs and cit , wryattme against said City
V z APPLICANT UNDmaniumoc of e gmnu NDS pc OMPLY WITH ALL NON-POI Issued by: D �Z-L?�'
i
SOURCER
" ' e Re-roofs
Sigoa um or Applicaro Consmnor D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or runic building ocmpantstom or handle hassmom material
u deBmd by the Cupertino Municipal Codc.Chapter 9.12.and the HcaW and Safety
.Sccdon 35532(6)?
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or Nino,bra ding occupant use eyuipmem ar deviw which If a roof is installed without first obtaining an inspection,I agree to remove
emit havallom mi
air conunanu u fined by the Bay Area An Quality Maoagcmcm all new materials for inspection.
Dis ncsT
❑Yes u
I have mal the hvanlwsrtwe' quimmcn rClupnr495aftheCalifor-
maHcaI"Safely Cmdc,Suyom155n5.2557J Sl4.lurulcnusmd thairthc Wilding
dam est curmnUY h a�W�Z
Upomihiliuy to ratify de oxup u of
mquimmcn c esuora Cenirean orOca Signature of Applicant Date
Owner or out orisd aOa
All roof coverings to be Class'n"or better