08050154 CITY OF CUPERTINO t:>. a7��± .�����a !rr'
BUILDiNC D1VIStON Pri, rr LQy�fa;"'"'ll`YJ
BUtLDINO ADDRESS: PERMrr NO.
1.02.61 BUBB RD DPR CONSTRUCTION INC 08050154
NEWS NAME: P1114M ISSUE DAT$
Al'111'.,F'COMPUTER 1450 VETERANS BLVD 08/11/2008
PHONE: SANITARY NO. CONTROL NO.
(650)474-1450
ARCHITECMDOGINEER: SUHDINO PERMIT INFO
HLDO ELEC[• PLUMH idECFI
9 ottOnI LICENSED CON ItAC1OR'S DECLARATION Job Description
O
I bereby affirm that 1 am]unused under provision of Chapter 9(commencing:. p
*dmSccdn7WOor0i,W=3of6eeu$i^MandPr'ofcawmcodc.mdmylimnis COMM'L TI OF EXSTNG 20, OOOSQ BLDG, NON—BRNG WL,
W full force and effect,
i5een,Ciata Co 0 9� NEW HVAC& FINISHES—EXTERIOR WORK INCLUDED.
Dam Conaacw'
ARCHrfEcrs D of
v
I underscatrd my pion shall be used u public recaeda
L ,
I i�� Lkcn ed Pm[asionai
IM
OWNER-BUILDER DECLARATION.
50 1 hereby affirm that I am toeatpl from the Cosmo;CoAny License Law o fo the
my �0
n 9 folbwing utasom.(Section TOSl.3,Htrsioaa and Protexdnns Cade:Any cltY or eouaty .
$V which requires a permit to construct,alfiM improve,demoish,or repair any structure
prior to its issuance,i[so requires the applicant for such permit to file a signed statement -
< tier bets licensed puuwaatlo due provisions oC the Camractor9 Lhamsc tsw(C3tapta 9 Sq•Ft.Floor Area Valuation
O (wmmatcing with Stxtiot 7000)ol Dtvisbm 3 of the Hnuitnw and Prolusions Code)or �,
S ttm hail escape therefrom aril due Uasb fa the alleged ettemption.Any vlolatfon of
Susiom 7031.3 by airy appScutt[or a permit subjtxts the sppruant to a civil penahy of
no more them live hundred"Ire($S= 3 5.7 2 0 0 0 8 64 Number Occupancy Type
❑I.a owner of the property.or my employea with wsga a their sale compensation,
wig do the work artd tba shu mm is amt imemded aroRarod forsak(Sec.70M.HW=u
and Profession Code:The Contractors I kcn Law docs not apply to as owner of Required inspections
property who builds or Improves them n,andwhodoessuchworkhimseltorlhmujbhis
owe employee.ptevided thalweb impmwoaU rte as inbsrded aroffbW forsala.if.
howuvm Iha buiWing or Wwmvamm to soW wkWnonc yar of completion,ire ownv
builder wig have the Audra of provinS thu he did not build er Improve for purpose of
Cb.>
❑>,u orvrer 0<the preperyG sm eclualvcly contracting with lieetned contractors W
construct the projecs(See.7041.Business orad Profession Coda:)The ComraetWs U.
crena Law docs not apply to as owner of property rico builds at Improves tMmon,.and,
who comuun told such projem with acontraem(s)Licensed pursnottothe Contr gimes
Lierass LAW.
0 1 am asempt under Sat .B a P C for Ws reasonDate
WORKERS COMPENSATION DECLARATION �`� i v I ��1v✓
I hereby drum under penalty of perjury amu of the following declarations:
❑Ilr m-dwillmainuinaCa dfic"ofComntmseif-iawm,for W ketscompm- •��i7 t.. >y b
sailor,as provided for by Section 7700 of&a tabor Code.for the petfotmsna of.the
work for which this permit Is issued.
❑1 have and will maintain Workers Compenakon.fosomooe,as required by Scaion ppp
3700of the Labor Code.for the prrfornumce of site work for which this permit is issued
My Worimes Compensation Inaramce artier and Policy number ate: /'T ✓ V�I V
c,"icr N.cTls aJ'"'o rrr. xm:ttl'd t Sal 3�f9 S
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
CrItissection m:cdm be completed Ifthe permit Isforesto hundred dollar(5100)
orlesa
I certify that is ire performance or the work for which this permit is iss"I shall not
employ any person in any munerso u to become subject to the Workaes'Canpensadon '
Laws of CalUarrIL Date
NOTICE TO APPLICANT:If,ager making this Cenilae of Exemption,you shmid
become snbjact to We 9t'eakers Compemitlon provision of the LAbor Code,you must
rJ ZO forthwith comply with such provision at this permit shah be doemod revoked.
Z
CONSTRUCTION LENDING AGENCY
r•1
1 hereby 8111um that dem is a omtnrttctiaa lending apcncy for tba porfttrtna cc of
a> We work for whish this paamh is issued(set 3097.Civ.C.)
I Q Lcnda'sNamc
0 z LendoesAddress
U O 1 certify tut I have read chis application ad stere that the above Wormatioa is
V.- correct t agree to comply with all city and county ordinances and suite laws relating to
0 bulhlisg consbuclion,and hereby auhorim repnnumnives ord,13 city 10 enter upon We
airove-mcadoned property for inspection purp=L-
(We)aPee to save,indemnify ad keep him tie City of Copwtino sgalnu 00
.t CA usbgitic%judg meowcosu area expenses which mmy in Guy way accrue againstsNd City
()�T in eon"ue=of tie Senting of this permit.
APPLICANT UNDERSTANDS AND Wt COMPLY WITH ALL NON-POINT Issued by: Dai
SOURCE TIONS, S v
SI rc .AlipliamtlCanuaetor ms's.-•rj. ef Vale /
,Re-roofs
HAZARDOUS Ass DISCLosURE Type of Roof
Will the appli Or I—b mg OCCUPWILstomorhamdk:haxardennutletiai -
a aenacd by de Cupertino Code Chapter 9.12 and the Health and safety
-F=
by 2333upert
❑y
y
us
G44All roofs shall be inspected prior to any roofing material being installed.
V/111 the applicant err futtem building**=psm moa equipmcut or&Men which If a roof is installed without first obtaining an inspection,I agree to remove
District? air eomanunsrres u aetited by the say Ana Air QwTlry Managcmcm all new materials for inspection.
❑ya t
l bwc teed the 1prallousmu1er,4131m nemcros,mder Cmpler6.93 of ft Califor-
UhHalthhsoferyCaufe.Smiom2550.25333and255M.IwA=md*Kifdte building
does not currently have a lona,dot it is to ponsibitity to notify the oeeupant or the
tcqufrcmcnu tut be flet prWr e' of a of
mgu 'Signature dfApplicant Date
agent Vmile All roof coverings to be Class @R'Or better