08030159 CITY OF CUPERTINO �ts'Ar,Y
BUILDING DIVISION PERNIIT kCFO1VTRA FORORMAT,ION "'
BUI 1 G FSS: v PERMIT NO.
ORANGE AVE BLDG B TBD — TO BE DETERMINED 08030159
R'S NAME: PERMIT LSUEDATE
L RCI PROPERTIES LLC 09/05/2008
PHONE: SANITARY NO. CONTROL NO,
ARCH1 ECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uao LICENSED CONTRACTOR'S DECLARATION
fClap
C (busby )ol' Nall 3lftoBuunderndPrionsof Codc,r9(mmmaming lob Description
n i
wit llOcSection)alU)incl. aionSofNeBunnwandhofcasiunsCode.antlmylrtenxis $FOWL-2, 433 ' IN MULTI—USE BLDG B
O m in full rode and ettat.
p a z Lice Clm Lk.t .
�;,q DaN ConlruNr
qq 7W ARCHITECT'S DECLARATION
W1 undaunted my plata ilull W land as Public records
S t; Licensed Pmfeai.MI
OWNER.BUILDER DECLARATION
1 hent,a1Rm that 1 am acmpt from Ne Conuaciaes ucanae law far IW
N O following mason.(Sado;7031.5.Business and Pmfecsiuns Code:Any city or county
which require a permit to coneruc6 a1Ne improve,demolish,Or repair any urucNm
_Zy
prionun its lams.aha requires NeapPlieam for such Permit N fka signed uatemcnt
Nine hliccvcd peraantta NepmriNonsofthe ConuacmfsUansc law(Chapter9 Sq.Ft.Floor Area Valuation
(commencing wit Scelion 7000)of Division 3 ordte Business and Pvreaions Cade)or $316290
$ Nat W is eaarnpt rh-nrmm and dee bais far the alleged exemption.AM violation of
Section 7031.5 by airy Applicant f.a permit subjects Ne applicant to a civil penalty of
lot mare Nan rive hundred doll.ISM 3 5 717 0 5 8 .jVj$Wumber Occupancy P Y Type
do dre.,of And
pouts,. I. with Audi
(Sec.mm.Burd n,
avid Pt thewark,ands: swcture a suintendedsLi .Offereddu forale(Sec.On M,Busircss
and property.1m
Wilds Cada:The CanitacNh License Law Ems mlchima fan owmr is Required InspeCtlODS
Own crtYwW capre aimpmtsuch h imparmndwho da not ins.uth wakhimsr3fatNaugh his
awnempbe Wilding
Improvement
mid wi art not ouefcluded moetion.ered ran,alar.
Wilder a the Wilding or impmvemmtg tat widdn arc year or mm owcfor We owner.
Wilder will bate Ue burdctt of proving Nat K did lot Wild or implore for purpoac of
VA.—am of the property.am aclunvely contracting wit licensed commuters to
'cunstvct Ne Mica(Sec.7044.Bainry and Prefessions Cede:)M Consraccah U.
sense raw docs not apply N an owner of property who Wilda or impmvv Berton,and,
who nonce for such projects wit a contractor(s)lianaed pursuant to the Conran &
Llcum w.
❑lam craft m See ,B&PCf Nis o
a out
WORKERS COMPENSATION DECLARAMON
1 hereby affirm unt er penalty of perjury We,of Ne following declaratiorts:
❑I hart and will maintain a Cartifallof Covent It,elf-ina a ferworea sCompere
aeon,a pmtid
warrfpe by Sectio 3700 of the Labor Code.!a the per(oman¢of de
t for which tri,permit is ivatl.
❑I harm and will maintarn Wohefs Compensation I..u requuN by Section
3700M de labor Cade,fa the perform.oftc wart far which this Permit Is iswed. '
My W.keYs Compewdon Insmaocc earner and Policy number art:
Canhr. Policy No.:
CERTIFICATE OF ID EMP ION FROM WORKERS'
COMPENSATION INSURANCE
flLhsealm teed Out W canpketl if the permit h faonchunNed reliant(SI W)
Or leu)
1 certify that in Ne pufomame of IW work for which Nis permit is banned.I Hill ana
employ any person in any manrc xaa'lo bccoma sybiecI to Ne Workers'Compewtion
taws of Califo Da¢
Applicant t7, `
NOTICE P CA}7T:If,after making Nh Cenifiate of Eaemptien,ym Nmid
become subject(d the Werk.'s Compentiuon pmrisioM of Ne Ialwr Cade,you a=
wJ,z faMwit comply wit such provisions or this permit shall W decmr4 rewked.
'Z O CONSTRUCTION LENDING AGENCY
[-r ani to wart,I.which rNmisNpaetrcNhemV ifaaatceodns(Sice.nnlending agency far Ne penurmana of
3(19'1.Cir.e)
LaMCYs Name '
z Latrines Address
U C) 1 awry that I hate rad Ibh application artd",Nu IW above iNomatim la
gy E correct 1 agree to comply wit all city aanam!d county ordina arean rete Irelating m
C)V^ Wilding construction.and hereby autodm relu—Nadtea of this city N cnlcr upon Nc
0. anove-imjudg a property f.ie pecdm purprWhich ms
(Wa agree to ave,indemnify and keep hamka the City or Cupertino against
Z inCilmasjudgmf o.dhecom
flemand of Lhis awhich may in my way aectm Against said City
U z A APPLICANT
of Na granting of th permit. �/
'-" APPLICANT UNDERSTANDS'�AND
j WILL
r�COMPLY WITH ALL NON-POINT Issued by: Date
SOU 42.//`17 vv \
s or 1taouconuactar lA 8 Re-roofs
,a 6
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne a Cupertino
a future Wilding e.Chapter 9.12,
Kandla haardoua maeriil
dcRttnd by the Cupenim Murtinpal Cale.Chapar 9.1;and tie Health,and Safety
.Section 25532(a)7 'K
All roofs shall be inspected prior to any roofing material being installed.
ED Y. y Ne
Will to applicant or future Wilding occupant nsc equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
..ithLmdous air cm=in;Z IkOned by ft Day Area Air Quality Management all new materials for inspection.
❑Ya
I have mad On haardom materiaU requirtmcna under Chapter 6.95of Ne Calif..
nia Hcal"SafetYCade,Sca.25545.25533 And 25534.1 undusvld NU JNe Wilding
dol rot cu dY hast•ens tiro it u mY napovibiliry b mdfy Ne eccupat of de
mqui en hmuuW tpriormiaaaaeraewre.laram,ney. Signature of Applicant
Fre' j i S s/�P Date
ow r.at mi.degant Dam All roof coverings [o be Class'%?"or better