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CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
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BUTING ADDRESS:
0041 BOLLINGER RD
DELTA GROUPS CONSTRUCTION
PERMIT NO.
08080155
OWNER'S NAME:
PERMrrISSUE DATE
PACIFIC RIM PK LLC
2362 MCGAW AVE
09/18/2008
PHONE:
SANITARY NO. CONTROL NO_
(925) 468-0115
ARCIITECT/ENGINEFR
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
1 hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Division 3 of the Business and Profession Code, and my 'kensc is
REVISION —IN DRAWINGS FRAME PRE —FABRICATED SHELTER
in full farce anus effect
[License at�s Ix-. 7
TO CONVENTIAL FRAME EQUIPEMNT AREA—ORIG 08080155
Date. 1 7Cs .G; Contractor
ARCHITECTS RAMON e,&,&VWrkNO
NEW PERMIT.
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Secdon 7031-5, Busiryas and Professions Coda Any city or county
which requires a permit to consuucL alter, improve, demolish. or repair any structure
'
prior to its issuance, also requires the applicant for such permit to Bic a signed statement
Conemetor's Uc Law (chapter9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the pmvisions of the me
70D0) Division 3 the Business Prefeaxions code)
0
(commencing with Section of of and or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 6 9 3 4 0 5 2 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a cavil penalty or
rot molt than five hundred dollars (scam.
.'
❑ L as owner of the property, or my employ= with wages as their sole ccompensadon,
Required Inspections
will do the work, and the structure is not inteatded«offered for sale (Sol 701a,Business
and Processions Code: The Contractor's License Law does not apply to an owlet of
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property wbo latllds «improves drereon, and who does such work himself «through bis
awn employes, provided that such improvements are not intended or offered for sale. If,
however. the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improves for purpose of
ale.).
❑ I, sit owner of she property. am exclusively contracting with licensed con actors to
comm= the project (Sec. loan, Business and Professions code:) The Contractors U.
eerie LAw does not apply to an owner of property who builds or improves themon, and ,
who contracts for such projects with a contractors) licensed parasol to the Contractors
License Law.
❑ i am exempt under Sec . B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
i hereby affirm under penalty of perjury am of the following declarations
❑ i have and will maintain a Certificate of Consent to self -insure for Workers Compen.
.
cation, u provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is issued
❑ i have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is Issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: SnaV -LURID Policy No: 46 7114 W9
CERTIFICASE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
0-his section reed not be completed if the permit is for one hundred don, n ($10m
or lea)
1 cerury that in the performance of the wort for whrcb this permit is issued. I Shill not
employ any person in any manrcr so at to becomo subject to the Worker' Comperuadon
Laws of California. Due
Applicant
NOTICE TO APPLICANT: lf, after making this Certirrcate of Eumptioa, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pc ntit shall be doomed revoked.
w
CONSTRUCTION LE24DING AGENCY
i hereby affirm thin there is a construction lowing agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's None
Lendefa Andrus
I certify that I have read this application and suite that the alcove information is
correct. I agree to comply with all city and county Ordinances and state laws minting to
building conswcdon. and hereby authwria representative of this city to enter upon the
property for inspection ppeuea.
above-m/,ern/arnxd m
(WO) agree to save, indemnify and keep harnslG4 the City of Cupertino against
liabiuticajoagments, costs and expenses which may in any way accrue agalnu said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
•'� d
Issued by: Date //
sewp REGULATIONS-
Re -roofs
Type of Roof
Signature of Appliam/Contractor Dale
HAZARDOUS MATt3tIALS DISCLOSURE
WIB the applicant «future building occupant store or handle hazardous marcriid
as defined by the Cupertino Municipal Code, Chapter 9.13, and the Health and safety
Code, section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yu XNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit harardous air corntaminnarrts as Wined by the Bay Arta Air Quality Management
all new materials for inspection.
District?
g�,
❑Ym P
i have mad the hazardous materials nequircircits datder Chapter &M or the Califor-
niaHeahh&SafctyCodr, Socdons ZM.25333 and L"U. i wdasand thaifthe building
den lot currently hale a tonal- dtu it is my responsibility to notify the occupant of the
mg which mum be met prior to Lauanca ofa Certificate of Occupancy.
Signature of Applicant Date
t-_i '-+�llr ,! r U C C t' _ � `� ccri8
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All roof coverings to be Class jq. or better
Date .
Owner or authorized agent