06050117 Aa
CITY OF CUPERTINO A`^ +sa> e%-A' '�"d 7 '' ''''
BUILDING DIVISION PERMIT ..CONTRACfinR INF�URMATION
BUILDING ADDRESS: KAISER FOUNDATION HEALTH P NO'06050117
R'S NAME: FERMITLSUEDATE
KAISER PARMANENTE 1780
E: SANITARY NO. CONTROL NO.
7 (510) 559-5111
ARCHITECrfENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
iOC LICENSED CONTRACTOR'S DECLARATION Job DGSCrlpnOn
�r I hereby affirm Net I am licensed under provisions of Chapter 9 fmmmencin{
with Section 70f1U)aDivislon,Sof the Business and Irmfeafions Code,and my license Is
+�N mfullfarroameffect 7 T. I . -OFFICES WAITING ROOM, COUNSELING RM
i z License CI Lia.g ��' B 7
r�� Dau: /z-Oh coavanar 32271
ATION
f Ice
A my PIused n public
records
eo Liccrbxn ca m e
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Commerce,License Law for the
o o following mason.(Section 70313,Business and Projects.Cale:Any City or ce.my
3$ff which rectums a permit to commuc4 mllNa slur,improve,dea , mfour any sacrum
_Zvn prior or its isswr¢e,ala requires the applicant roruch pcmit in 0k a signed suumcm
i c Iwneklkensedlmru.mon da,pmviaimea rtheeonouesesu i.aw(chapter 9 Sq.Ft.Floor Area Vaogtfp000
55 $ (commeming with Sredm7000)of Division Sof the Business and Pmfeatimus Code)or
K that M LL exempt therefrom and the basis for the alleged eacnpdo t.Any violation of
Section 7031.5 by my applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
not marc than five hundred dollars(5500). 31609037 . 00
❑1,u owner of Ne pmpmy,m my employca with wages a Nelr ask compem dm,
will do the wart and theaacmmla not intended or offered fanate(Sec.7044,Basi^•`• Required Inspections
and Prefesslwns Code:The Contractors License Lew own
sr not apply te in owr of q P
property who builds m improves Nemon,and who dm such wort himself ea dumb hu
awn employees,Provided dist such improvements art Out intended aafferded for We,U,
lumvu,the building or improvement Ismid within aro year of mmpkdm.dre Owner-
builder win have the burden of proving dal he did not build or improve for purpose of
sale.).
I,a owner of the property..B exclusively contracting with licensed mm uses l.
coast La d project(See.7014,Business and rty who
rats Code)The Cmtracmra LI- tf13 !�4{nf'd'}tLWjT .
cense law does oro apply m ts wither of property aha sedbuildsp or Improve Cotem,and,
who.Law.for Stuck projects with aconvanor(O licensed pursuant to Ute Contractor's
Lkova Lew. /
I am axe P an Data P C for this reason rdy��oG - 2006
WORKERI COMPENSATION DECLARATION, (O�gTJf /,rye-wp
Ihanbyill mai under Cainfl w perjuryamtoof dukllowfng dociWaruadmu f4y�1a61(ff� U ((vim,
❑]ham and will maintain a CeNOcete of Canute to selFinsurt far Warkcra Cempcn•
anion.u provided for by Section 37M of the Iaba Code,for the performance of dte
work for which this permit Is Issued.
00101 I have and will maintain Workers CompensWon Insurance,u required by Section
370()of the Labor Code.for the performance of dte work for which this permit Muted.
My Workers Compensation Iwnnce artier and Policy number art:
Carder, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thk scrim need rot becomplau i If IM Permit Is foram hundred dollen(510)
or less.)
I certify dist In the Performance of the work for which this permit is issued.I"I not
employ any Forced in any musuru u m become ubjeci to Lou Workers'Comperleadom
Laws aff:LUarNa 4 /l�7 ^� ^^"'
ADPIicm C
NOTICE TO`AP ,after making NLL CenlOau of Exemption,you should
become subject in Ne Workers Compensadon provisions of the labor Code,you must
.JO forthwith comply with such previsions a this permit shall be deemed revoked.
'y' CONSTRUCTION LENDING AGENCY
'rr Ihereby affimthu dart lea constructum landing agency for du performance of
f�> dte work for which Nis permit LL issued(Sec.3097,Civ.C.) '
W O Lenders Name
z lenders Address
U C) I sonify then I have read this application and rude that the above infomadm is
ty (~ man.l agree to comply with all City and county ordinances and sum laws calming to
U building concretion,and hereby amhorre representatives of this city to enter upon the
W abovomemioned property for inspection purposes.
gy, (Wc)agree to asve,indemnify roti keep harmless the City of Cuperlino against
�Fy to IlabilNeLJudgmenb,costs and expenses which may in any way&case against said City
UZ in conaegucnce of the Snoring of Nis permit.
^ APPLICANT UNDE0.3TAyD�ND WILL COMPLY WITH ALL NON-POINT Issued by: Date 7
50/UIR.0/EffECU3t////a//�//y7p0/N//yJ
Sigh t rA am macmr — Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appliam m Ruure building acupanenae or handle huardous material
Rad by du Cupertino Municipal Cade,Chapter 9.11,and Ne Hearth and Safety
section 15531(0)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �o^
Will Ne Applicant or mann binding wCCllpimt ten equipment Or mviaa which -If a roof is installed without first obtaining an inspection,I agree to remove
emit hvxd..9,cmumimnts as delved by de Bay Ana Air Quality Management allnew materials for inspection.
D ucs7 ��
❑Yes
I hevc mad the hoard,..medals mquimmeam under Chapmr6.95 of Ne Califor.
dies nlN&.SafnyCode Sec%.15573 wW21331.1 to County M.P bt.f the
Jcea not ndy M w It u mY dinS
raponslMllry to notify Ne occupant of the
re wide .1toI.anmofaCcrtificateofOccupancy. Signature of Applicant Date
%�L r3^p
era auNarirzda cm Date All roof coverings to be Class"B"or better