07100221 CITY OF CUPERTINO `° ` '` �k,� '
BUILDING DIVISION PERMIT �����`��� �����' '
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� PERMIT NO.
BU(LD ���B� ss STEVENS CREEK BLVD TBD —'IO BE DETERMiNED 07100221 .
PERMIT ISSUE DATE
�ER'S NAME:
BOB RUA � 10/30/2007
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHI'iECT/ENGiNEER:
BLDG ELECf PLUMB MECH
� 0 � 0
i p p LICENSED CONTRAC7'OR'S DECLARATION 7pb DeSCflPC10l]
� V� I hcreby afGrm that I am liccnsed undcr pmvisions of Chaptcr 9(commcncins
; z � with Scction 700U) a( Division 3 of thc Busincss and Profcssiuns Codc ana m �ice� is INSTLTI� O F FORC ED C ENTR.AL HEAT I NG & AC SY S I NTO
�� y in full force and cf ,�,.� O L � . �?�`�' �� ATT I C '
�� ? Licensc Class
. F � pa� Conaaaor
� ARCHITEGTS DECLARATION
i a Q t undcrstanJ my plans shall bc used as public recnrds
)yU
' u. F' Liccnscd Profcssional
' � a OW NER-BU1LpER DECLARATION
j a� I hcreby ut7rm iAat 1 am cxcmpt Crom ihc Contractors Liecnsc Law fo� �hc
. p o (ollowing mazoa. (Secuon 7(131.5, Busincss �pd..erofcccions Codc: Any city or caunty
�$� which rcquires a permic to canswc4 ��r, impmvc, dcmulixh, or repair any swcture
� z� priar to i�c issuancc, alsu rcquires Uic applicant Cor such permit io filc a signcd stammrni Valuation
� < lha� he is liccnscd pursuanl to �hc provisions of thc CanUactur's Li�roosc Law (Chaptcr 9 Sq. Ft. Floor Area � 7 O O O
� t = -� �(commencing wi�h Scction 7000) of Division 3 of Ihc Busincss and Profcssinns Codc) ur
4 �.. Uiat he is ezempt ihcrcfrom and ihe basis (or �he allcgcd eumption. Any violanon o(
Secdon 703 t.5 by airy applicant (or a permit subjec�s U�e applicant to a civil pcnaity oC e Number Oecupancy Type
not more than five hundred do1►ars (5500). 3 5 717 O 9`.'C) V
❑[. u owncr oC ttie property. or my employces witM wages as the'u solc campensadon,
wili do ihe work, and ihe stmc:um is not inlended er nffe2d for sale {Sec.7044. Batiness Required Inspections
and Ptofessians Codc: The Contractar's License Law docs not apply iu an ownu of
praperty who builds o� impraves thercon, and who dces such work himself or duuugA his
own employccs. providcd ihat such improvemenls are not intended or otfered Cor sale. U,
however, the building or improvement is sotd within one year ot complcuon, ihe owner-
builder will have the burden oC proving �at hc did not build or improvc for purpox of
salc.).
❑ 1, as awner aC the property, am eaectusively conhacting with licensed rnnuxtors w
conswct the project (Sec. 7044. Businas and Pro[rssions Code:) The Contrutnr's Li-
ccnse Law dacs not apply m an ownu of propeny who builds or improves �Aeeeon, and .
who convacts for such pmjec�s wiU� a con�cactor(s) liansed pursuant w U�e Convxtofs
License Law.
1 am uemp� undu Sec. . B 8c P C for this rcason
.�ner Date _. .
WORKER'S COMPENSATION DECLARAT[ON
I hereby �rm under pemlty of perjury one o[ the fallowing declaralions:
I hsve and will maintain a Cenifcatc of Consent to sclf-insure (or Workcfs Compen-
sation, as provided for 6y Secdon 3700 of the Labor Code, for ihe pedormaircc of �tie
work for whicd �his pertnit is issucd.
❑ I havc and will maintain Worker's Compensatian Insurance, at �equired 6y Scction
3700 of thc Labor Coda (or thc perfortnance oC �he work for which �his permit is issued.
My Workers Compensatian Insurance carricr and Policy number are:
Cacrier: Paliry No.:
CER7'IFICATE OF EXEMP'fION FROM WORKERS'
COMPENSAI'lON 1NSURANCE '
(77�is scction necd not bc completcd if the pccmit is Cor anc hundred dollars (S I00)
ar lcss.)
I cenify Ihat in the pertormance of thc work for which this permit is issued, I shall not
employ any person in any ncr So,azW o ic the Wo Co
Laws of Califomia. Datc '��' � G �� �� ��
Applicant
NOTICE TO APP[.ICAM: If, af�cr making �his CcrtiGcam of Excmption, you should
bccome subjcct w ihe Worker's Compcnsation pmvisions af Wc Labor Codc, yau must
� O forthwith comply with such provisions or this permil shall bc dccmcd ccvokcd.
z '"'' CONSfRUC7'ION LENDING AGENCY
F � 1 hcrcby aCfirtn that thcre is a consuuction Icnding agcncy (or thc performance oC .
�C, � thc work fur which this permit is issucd (Scc. 3097, Civ. C.)
W Q Lcndcr's Namc �
= z L.cnder's Address
U � I ccrti(y Ihat 1 havc tead lhis application and sia�c �hat Ihc abovc infortnaliun is
�� cortcct.l agrce to comply with all city and counry orJinances and state laws rclx�ing lo
0 U building conswction, and he�eby authori�e reprcsentatives of ihis city to emer upon lhc
� a aM1ove-mentioned property for inspecuon purposes.
(Wc) agree to save, indemai(y and kecp harmless thc Ci�y o( Cupcnino against —'�
H � �iabilitia, judgmcn�s, costs and expcnscs which may in any way accruc against said City �
O Z in consequencc oC t6c granung of this permi� Date /(/ ������
� APPLICANT UNDERSTANDS AND WILL COMPLY WI'fH ALL NON-POINT Issued by: _
SOU RECaULATIONS.
� �� /v � �d ''� ? Re-roofs ��---��
Signaturc o pplicantlConuactor D8� • I • y�C Of �.00f
HAZARDOUS MATERIALS DISCLOSURE
�11 Ihc applicant or futurc building occupant storc or handlc huardous matcrial
fincd by thc Cupectino Municipal Codc. Chap�er 9.12, and thc HcalUi and Safety
.e. SccUon 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
�y� j�No ,
�� If a roof is installed without first obtaining an inspection, I agree to remove
Will ihc applicant or fuwrc building occupant usc cyuipmcnt or dcvices which
cmit harardous air contaminan�s az dcfincd by the Bay Arca Air Quality Managcment all new rr.aterials for inspecrion.
Disuict? ` /
Q Ycs �yu
(—
1 havc rcacl the haiardous matcrials rcquiremcn� undcr Chaptcr 6.95 0( ihc Calilor-
nia Hcalth & Safery Code, Sections 25505, 25533 and 25534.1 undcrsiand that if �he b�ilding
docs no� curtcntly have a tcnan4 �at it is my responsi6ilily to raul'y thc occupant af �hc
rcyuircmcn�s which must bc met prior w issuamc r a c��;r�a� or o��,�ry. S ignature of Appl icant Date
� ��, �
���s— ��� `z'=^- All roof coverings to be Class "B" or better
Owncr or authorizcd agcn �a� -'