07100015 CITY OF CUPERTINO 7 � , ` � `
BUILDING DIVISION pERMIT ��I�'1������"�>�������� '
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,,_; : ; :
PERMIT NO.
BUIL q � r � c ��� es �ILVERADO AVE TBD - TC) BE DETERMINED 07100015 .
/ER'S NAME: PERMIT LSSUE DATE
TAM, ROBERTO � 11/14/2007
PHONE: SAMTARY NO. CONIROL NO.
ARCHITECI'/ENGiNEER: BUILDING PERMIT INFO
BLDG ELECi PLUMB MECH
� � � 0
u p p LICENSED CONTRACTOR'S DECLARATION JOb DeSCI7PU0i1
� V� 1 hercby �rtn that 1 am liccn4cd under provisions oC Chap�cr 9(commencing
_ z� wiih Sccuon 7000) ot Division 3 of thc Busi�ess and Prolcssions Codc, and my license ia l C B � PA� � I 0 ENC LO SUR E
°� y in full force md ef[ � Z� 3
j� z[rcensc C�ua ��• � S�STAR S�ROOMS PD B SL �S" 10 7. � � 1 �/ 1/ 2 � � 7
� �, � Datc ConuactorS.� r
ARCHITECI'S DECLIS�A`17 N
�� e I undcrsund my plans sl�all6c uud as public rccords
m
4 O y Lii:cnscd Prufcssional
y � OWNER-BUiLDER DECLARATION
�' � heroby alTirm lhal 1 am excmpt Gum thc Conuactor's Liccnse I.aw for thc
� p o following icason. (Scction 7031.5, Busincss md Profcssiom Codc: Any ciry or county
y� Pi which rcquiccs a permit to conslruc4 altcr. im{xove. dcmolish. or repair any swcmrc
prior to i�s istuancc, also requires �hc applicant for such permit to filc a signed sta�ment „
� x � that he is licenscd pursusnt to �hc provisions of thc Conuactor's Liccnsc Law (Chaptcr 9 .>q. Ft. Floor Area Valuation
� F- $ (commcncing with Scction 7000) of Division 3 of �hc Businus und Profcssions Codc) or � 3 9 8 9 7
y �... �hat he ia e:empt �heretrom and the basis Cor the sllegcd eumpdon. Any violauon of
Section 7031.3 by arry applicant for a pertnit subjecu ihe applicant to a civil penalty of 3 6 9 3 9 01 �) Number Occupancy Type
not mo�e U�an five dundied dollars (5500�
❑ I. u owner of the property. ar my employces with wages as their wle compensation,
will do the work. a+�d ihe stcucture is not intended or otferod for sale (Sec. 7044, Business Re uired Ins ections
and Professions Code: The Conuacwr's License Law does not apply in m owner of Q p
ProP�Y p'ho builds or improves �hereon. and wM does such woric himeelf or Uwugh hia
own employces. Provided thst such improvemen�s ue ndt intended or otfeced Cor sale. If,
however, ihe building or impmvement is suld within one yesr of rnmpledon, ihe owner
buildu wiR haw the b�uden oC pmving that he did not 6uild or improvc for puryose of
sak.).
0 I, as owner of �he property. am eaclusively conuatting with Gcensed rnnuaclors W
constnut the penject (See. 7044. Business and Professions Code:)'1]ie Conuacwr's Li-
ccnse [�w docs not apply to m owner of properry who builds or improves thmeon, and ,
who convacts for sceh projects with a conuutor(s) Iicenxd pursuant to �he Convscwrs
License Law.
[ am exempt under Sec. , B k P C for �his �cason
, � Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty o[ peryury one o[ ihe following declaralians:
❑ 1 hsve and will mainuin a CeniGcate o( Conunt to xlf-insure for Workcr's Compen-
sation, u provided for by Section 3700 af cAe Labor Code, (ar ihe pedormance of the
worlc for which Ihis permit is issued.
❑ I have and will maimain Workcrs CompcnsaUon Insurancc, u mquired by Sccdon
3700 of �he Labor Code. Cw the pedarmance of the work for which thu peemit is issued.
My Worke�s Compenution Insu[ance nrricr and Policy number are:
Cartier. Poliry No.:
CER77FICA7E OF EXEMPIION FROM WORKERS'
COMPENSATION INSURANCE '
(This scctian necd not be completcd if the pecmit is for onc hundred dollars (S10(q
or less) �
I cenify thu� in thc performancc of thc work fw which this permit is issced. 1 shall aot
employ any person in any manner so as to become �ect to the Woricers' Compensauon
Laws of Cslifomiy„D�1c /�— / v " ��.
Appiicant « �
N077CE 7'O A LICANT: If, aftcr making this Certifia�c of Excmption, you should
become subject to lhc Worker's Compensation pro�isions of �hc labor Codc, yau must
� O forthwi�h comply with such provisions or this permit shall be decmed revokcd.
z "'' CONSTRUCTION LENDING AGENCY
[. �-�+ I hemby s[lirm that tlrcre is a rnnsuucdnn lending agcm.y far thc perfurmancc o! .
p�,,, � thc work (ur which this permit is issued (Scc. ]097, Civ. CJ
W� A Lendcr's Namc '
] z Lcnder's Addmss
(� � � certifY Iha� I have resd tlds applicatian and state U�u tde above informaurn is
w ►� cortect. 1 asrce w comply with all city and connty oNinances and sute laws mlating to
0 U buildin6 consuuction, and hcrcby authoria rcpresenutivcs of this city m cntcr upon �hc
W above-menlioncd pmperty for inspenion purposes
a (Wc) agree to save, indcmnify and kecp harmless �he City of Cuper�ino against
�,,,,� � liabilitia, judgmcnls, cosis and expensea which may in any way ucmc against said City
V z in consequencc oC t6c granting of this permil. Date
r+ APPLICAN'C UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SODRCEREGULA�
��i� I/-/y -oy Re-roofs
Signazure of ApQli t/Contrac�or Da�c
HAZARDOUS MATERIALS DISCLOSURE Type of R�of
Will thc applicant w futurc building occupant storc or handlc ha•rardous ma�crial
Icfincd by the Cupenino Municipal Codc. C6aptcr 9.12, md the Health and Safety
� ,Seclion25532(a)? �/+ All roofs :.hall be inspected prior to any roofing material being installed.
❑ Ycs (�no
�` If a roof i:. installed without first obtaining an inspection, I agree to remove
Will thc applicant or fuwre building accupant usc cquipmcnt or dcvices which '
emit ha•rardous air con�aminanis u dcfincd hy the Bay Area Air Quality Managcmcni all new m�terials for inspection.
as����� ,�+
❑ Yes W I Nu
i
1 havc rcad the hvardous ma�crials requircmcnu undcr Chap�cr 6.95 of Ihc Glifor-
nia Flcalih & Safcty Code, Sections 25505.25533 a�u125534.1 undcrsund tha� iCtlu 6uilding
does nol curtcnUy have a tenan�, ihat it is my responsibiliry w noufy �hc occupant of the
requiremcnLS c must met priur to � i '`� of a Ccrtifica�c a( Occupency. Signature �f Applieant Date
��� �-���''`�� �� � All roof coverings to be Class "B" ar better
Own�thor'v.cd agcm ���