05110001 CITY OF CUPERTINO +° ^Pi r. -` ' ��`' ` '' a•�e
BUILDING DIVISION PERMIT �CURA,C ' ` IN "UMA'TIc) s*¢
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BUILDING ADDRESS: ` ' PERMIT NO.05110001
10038 ORANGE AV
R'S NAME: PERMIT ISSUE DATE
05/04/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITECIYENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
tom . 0 0
am'z LICENSED CONTRACTOR'S DECLARATION Jot)Description
l u I basely IMM Nm Reacted 1Reacted under Pmviniam of Chapter 9(commencing
withSection 7000)ofDivsion 3 oft,Business aha Profusion,Codo.and my Iicevc s
±�� in full force andercect. MULTI USE—RESID 2 , 710/GARAGE 474 ' /COMMER 1, 705 '
)ME LicenseCala
Data—
Coruscate CLINIC 10036/RETAIL 10038/RESID 10040 ORANGE
i 'te
ARCHITECTS DECLARATION IST FLR-CLINIC/RETAIL 2ND FLR RESIDENTIAL
f 1 understand my plana Mall he used a public record,
SyU
c Licensed Professional
wt 5 OWNER-BUILDER DECLARATION
q I Mosby affirm that 12 1 "empl from Um Continues MLaw for the p O fallowing meson.(Sudan 7071.5,Business and Pmfessians Cade::My y c airy as county
< which require a permit On conswcL altee improve•demolish,ar,peu any umctem
�zs prior to its iaunce,&I.raquiru the applicant far such permit,file&signed slatemrnl Valuation
< that heulicensed Ironical rothe provisionsofMeConnector's Licenselaw(Chapter 9 Sq.Ft. Floor Area
e�ct (commencing h
with Section 7000) of Division 7 of the Business aha Professions Code)or $609374
L' $
that M s con-pt therefrom and the basin far the alleged eamptaa MY'loath-of
Section 1071.5 by My applicant for a permit subject,the appuesat on a civil Panalry of APN Number Occupancy Type
rot mem the fow hmut,d dellaa(m).
❑I,u rwner afthe property.m mY wFloym with wage u thele ante conpensauro,
will Professions Cd&-The CoomamsLimsorawdoes n[opply to an Butlrcas Required Inspections
proand Rofmnobu Cade The Conucmr's ndante law dao not apply ir nd soar q P
Man can who s,Provided
ro orimprowa h impr andante=notdonesuin walk halrsdrmthrough his
houa,er,the ee Frog or i del tech improwmrnu are not ear Ofc moQered far ale U,
bmvewethe buildinguiimprowmrntI&anld wild ane Year of complede.the owe of
Wilder NB lave the Wrdrn of proMng del k did Out Wild m Improv fm purpose of
a
1.u este of the pmes'"Y,w ashmly canuuaing with licensed conuacm,In
uuct to Project(Sec.7000,Businaa and Pmfessiam Cade)The Comtracmr's Ll-
a.s,law does am apply no an nwser of property wlm build,or Improws Peron,Md.
who contacts for smth projects with arnnoatwHO licensed personal to the Co rskmora
License Law.
❑lamesempt
DECLARATION
1 bemby Lain,under parody of perjury arc of the following dedar i imus
I]Ihawand NIImaintain• U.3700of fftLnbmCod- fw fm Wm. Camprn
salon, r proviMA fos mi Senior 7700 a(the Vhor Code,fos tha pcRatmame a(the
safe for which thin permit is issued.
❑I haw and NII maintain Wmi es Compensation Insurance,as required by Sermon
3700of the lastrCade.fm the podormaxe of the work for which this pamok in laced.
My Woraes Compa"no hhmrence curia,and Policy nomMs arc:
Carder. Polley No.: _
CERTIFICATE OF MEMP ION FROM WORKERS
COMPENSATION INSURANCE v
CnsuWca reed rot W ccrmpleed Uthe(emelt Is fora,hundred dollaa(SIM)
or less)
1 enify Pmt in the performance of the work for which Nin permit s Wised,l NN rot
calplfy any person In NY reform.m a m lemma ryry"lfrLI a lM M�admta'CAmpemadan
Laws of
—
NOTICE TO AFIPLICAWT.If,Wr maCril this CcdiOc,of Exemption,you Should
become subject,the Worker's Compeaadrn provisions of the labor Code you mut
0z
forthwith comply with such provisions or this Permit Mall W ticemcd mwked.
z r~rA.. CONSTRUCTION LENDING AGENCY
[.v Ibaes,air=the them Is a coennocunn lending a6ay for the pcdcarnance of
ani the work fm which this Permit Is issued(Sm.3097•Civ.C.)
W�0 leader!Mune '
z lander!Addm..
U O 1 certify Nn I Mw mid this applicu oo and tete that the&have Imconstion is
P Corea 1&&me to comply with all city aha county orfinances and sus laws mlaling to
�U Wilding construction,and hereby authorim represenuthes ofthis city to enter upon Me
>"W above-menuuned pmperty for inspection Purposes
d (We)agree to saw,indemnify and kecp harmless the City of Cupertino against
rF.h cA Itabilidu.JWgmenu,emu and"Forces which may In any way seems against aid City
U in conse carce,of the Swung of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUf.�
DISCLOSURE Type of Roof
WIII the applicant or future Wilding occupant atom or hands hazardous material
defined by Me Cupethen Municipal Code.Chapter 9.11•and to Health and Safely
Section 15531(,)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ]No
Will the applicant m future building occupant use equipment of devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh hazardous I,coouminanu as de0md by the Bay Area Air Quality Management all new materials for inspection.
District? --//
❑Yes Hrvu
I haw mad die ha rdous Materials mqulreme s under Chi 6.95 of the Cali(or.
nia HealLh&Safety Coda Seeuans25505,73533mdZ5530.lun&e dthatlfthe building
dors not currently haw a"nam.that it is my responsibility in notify the occupant or the
mqulmmeny whMust Par,inaanm an certreate or acapaney. Signature of Applicant Date
All roof coverings to be Class "B"or better
Owner ar wthonad agent V U Da,"