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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT;CCSNTI2ACTa?Y
BUILDING ADDRESS:
PERMIT NO. 06070077
pts ER'S NAME:
PERMITIESUEDATE
GATE OF HEAVEN
PRME:
SANITARY NO. CONTROL NO,
ARCHI7ECTIENGINEER:
BURRING PERMIT INFO
BLDG E(ECr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I Wmby affirm lout I am licensed under pmvisiou of Chapter 9 (commencing
with Sued.. 70fp) of Division 3 of the Busimas am Professions Code. and my license is
. full force andeRem.
TWO ARBOR STRUCTURES
Licenm Class Lk. N
Da¢ Contractor
ARCHITECTS DECLARATION
I understand my plans shall W used a public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aRrm that I am acmpt from Ne Conducmfa License Law for Ne
fallowing mason. (Section 713 1.5, Business and Professions Code: Any city or county
which cf,do, a permit to construct, shun Improve. demolish, lir repair any swctum
prior to its issuance. Alan mquires the applicant for such permit to file a signed sulcmcm
License law(Chapter 9
Sq. Ft. Floor Area
Valuation
visions of Ne C.ntrei
that he islicensed pursuant In the prolra
Section 7000) of Division 3 of the Business and Profcallou Cock) or
$30000
(commencing wild
that he Is exempt themrmm and the bub for the alleged cumptioo. Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant 10 a civil penalty of
APN Number
Occupancy Type
not mom than ave hundred dollars (5300).
❑ 1, an owner of the properly, or my employees with wages as their tele compensation,
Required Inspections
q P
wits do We work. and the swctum boat intended or offered rarnle(Sec. 7044, Budnea
and pmfemiem Cade: The Con muniti's License Law does tet apply m an Owner of
property who dui lds or f m proven Mercer. and who dacessuch weak himself w through hu
own employees, provided thmsuch Improvements art nutintendd orafferd forsale. If.
however, the building Or improvement is sold within one year of comple kin, the .wner-
builder will have Ne burden of proving that he did net build or improve for purpose of
sats.).
❑ L a owner of the property. am sommovely... mutin{ with 11.. d conmctms an
conerect We project (Sm. 7044. Business and Prerci dam Com) The CO.ucmfs l-
ean law dace out apply to an owner of property who wilds ser impmw Osman. and.
who ten tech pane a�ncwqz)mmdusm mthe COntraYOhL
coraDIun a earlsB k P farmusate
3_j7
WORKERS COMPENSATION 0 DE RATION
I hereby of too muter penalty of pnjmy oro of the fmloWng declumimmt
Q 1havesodwBlmdnuin,Ce ammor Carsonmself-imumwwod SCompco-
miles. u provided far by Sued.. 37.0 of the Labor Code, for the Wife-- of the
work for which this permit is !need.
❑ 1 have and will maintain W.rkefa Compensation imuMa. at mnluded by Section
3700 of the labor Cock, for the performamm of the wart forwhlch met permit is issued.
My Woftes Compensation Tom sanco cantor and Policy number me
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need net beeomphctd If the permit is formac hundred dollen ($100)
lir less.)
1 cerdfy that In the perfomanee of the work for which this permit is issued. I Nall not
employ anypc'n mann Aa5 an ajctm a worker Compensation
Laws of Caii(
Applicant
NOTICE TOPPLICANP. If. after making this Cn ca of don, you shW5
bcoomeaJ WatCam n Nor Coe. you muss
forthwith comply with such provisions or this peed, shall be decmca invoked.
LENDING AGENCY
CONSfRIs
1 appron thus dorm b atom agency for are per(ormnmco of
c.30
,
7, Cis,
a the work for which this permit b issued (Sue. 7097. Clv. C.)
Mi s ed (Sc
Lendefa Name
'
r lenders Adams
1 comfy Nu I )save rem Wa Wimamion W sum thus the above information is
cormct. I agree in comply with all city and county oNinun:o and suss laws coli ung m
Wilding ccem uctim. and hemby amhorim repreanumivesOf this city m crue., in the
7 ab.ve-mmoorcd property for inspecum Prime.
(we) i gme to ave. indemnify and keep barmlea the City of Cupertino agalmt
0 Isabiliumajudgments.eosn and eapume, which may in any my accuse against said City
[ nc ranee "film {ranting of Nb permll.
""=9011
A LI NT UNDER A DS AND WI L COMPLY WITH ALL NON -POINT
Issued by: Date
S U EQULATIONS.
b
8-3.0
Re -roofs
Type of Roof
n roof Applican✓Conua se, Data
slug-..,
lHAZARDOUS MATERIA CLOSURE
Will the appllam orfutorc building acupemsbom erhandle himmous material
u dented by th. Cupenino Municipal Code, Chapter 9.12, and the Health surd Safety
. Soman 25532(a)?All
roofs shall be inspected prior to any roofing material being installed.
C:ly.
If a roof IS installed without first obtaining an inspection, I agree t0 remove
Will he applicant or future Wilding occupiedeuse equipment or devices which
-tell haurdous air contaminants a defend by the Bay Arta Air Quality Management
I
all new materials for inspection.
DismicR ` ^
-
❑Ya r06
I have reod the haardmts mamrialsmqulmmenu under Chapter6.95 of the Califon
ilia Health IyCode, Scodons15505.25533em125534.1.ndcnundihalff building
time not men ly haw a dust It Y meponsibllity u netil'y Lt. occupant lir the
'.radisuaneeof.0
require n hmmyab.�l fiauorocccupancy'
Signature of Applicant Date
AA.mnann
All roof coverings [o be Class "B" or better
r anthalred agent D,te