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05090218k U CITY OFCUPERTINO BUILDING DIVISION PERMIT ,(`()NPRt'LU�"T()R XN' ° �tMA,'T�IAi, �2 � ,. .�` +&4'��'ik-� BUILDING ADDRESS: PERMIT NO.0 5 0 9 0 218 2622 MARIANIST WY XS NAME: PERMIT ISSUE DATE MARIANIST PROVINCE OF THE U.S. 02107/2006 NE: SANITARY NO. CONTROL NO. ARCHITE VENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 Imreby Lam that l am lmcrr¢d ions under provisof Chapter 9 (commencing with Section 70110)afDivision Sof the BusiM••and Pro wilmuCoM.snd my licensee in fall(a. mdeffe ADD 6922.99'/REMODEL 14,427.261 License Clue Damte CContmuractor D ADD BED/BATH/ENLARGING KITCHEN/DINING RM ARCHITECTS DECLARATION CHAPEL & REMODEL THROUGOUT I understand my phNW heated ed u public..'al..'a Licensed Professional OWNER -BUILDER DECLARATION I hemby affirm that I am amount from the Con"clor's Ueeuc law for the following mason. (Section 703 1.5, Business and Profassium Cade: Any city or county which mquireaa Permit to eorwnc4 slme improve, demolish, or repair any suunum prior in its issuance. also requires tie applicant for such permit to rile a signed so mment Contractor's Liamc Law 9 Sq. Ft. Floor Area Valuation that he is licensed Pronamt w the provisions of the (Chapter (commencing with Sutton TWO) of Division 3 of the Business and Professions Corm) at $2937603 Nat he u ewmpt therefrom and dm basis fm the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant be a civil penally of not mare than five hundred dollars ($500). ❑ I, u owner of dm property. w my employcu with "m a tisk wle compensation, will do the wank and Meauuomrt is not intended oroffmal fm sale (Sm. 7044, Business Required Inspections and Profession Code: The Certainties'. Lim. Law does not apply m am owner of q p property who builds or improws income. and who does such work himself or through his own employees, provided that men improvements are not Intended Or offered for We. IL however, the building or Improvement Is sold within one year of completion, the mvner. buildu will have the burden of proving that he did non build or Improve for purpose of cam.)). , owner of the property, am exclusively contracting with licensed conuw u uR4n m rOmtma the project (Sec. 7044, Busineu and Professions Cade:) The Contractor's U. «rue law docs not apply to an owner of propenY who builds or improves thereon, rod, who contracts for such pmjecm with a comms or(s) liumed pursuant to the Cement's License Law. under Sec. B k P C for this mason :�9.�G= I .� Dam C2zo! r WO�ENSATION DECLARATION I Mreby &Man under penally of pedury ore of the following declanliom: IrecacmIn im and will mNnmin aCertl0uan of Convent w self -insure for Wodtcrs Compcn. , u provided for by Section 37M of the labor Cade, for the performance of mefor which this permit is issued. haw and will mainum Worker's Compensation Imunnce, u required by Section of the labor Code, for the performance of the work far which this pemdt Is Issued. orker's Campersation Insuranco prier rod Policy number art: ' Carrier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This auction need ant be completed If the permll ts foram hundred dollars (SIM) or ICnJ I certify that In the performance Of Ne work for which that perm[, Is issued. l Ntll am employ anyperwn lo any mwner w yay to bcanme wbjecl a tM Workers' Component. Laws of Cgqtfomia. Dam Amt •Lei Applearm NOTICE TO APPLICANT: IL afro, making this ominum of Exemption. you should become anbjm to Ne WorkeYs Compemnion provisiom of the labra Code, you most faMwith comply with such provili oul m this permit shall be asumed revoked. CONSTRUCTION LENDING AGENCY 1 hemby aflres Nat More Is a comtrnctimn rending agency far the penurmaruc of Me work fm which this permit is issued (Sec. 3057. Co. C.) Lc dets Name Landers Address I certify that I have mad this application and atom this the above Information is torten 1 arae to comply with all city and county ordinances and sum laws totaling to Wilding construction, and hereby submarine representatives of this city to ensu Oran me aluve-mentioned pmperly for inspection purposes (We) agree to taw, indemnify and bup harnleu he City of Cupertino &l j lubilides, judgmcau, costs and expense which may In my way amus against midCity In comaqumum of the $.lies of this permit. ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:9 Date SOURCE REPULAnONS o� Re -roofs Type of Roof Ignuureo Appli<anVCanuecto, Data HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupenumrc or handle hauNaus material Oned by the Cupenian Municipal Cade. Chapter 9, 12, and me Health and Safety Section 25532M)7 All roofs shall be inspected to any roofing material being installed. ❑Yes u prior If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building ucupom tau equipment or devices which It harudous air conummme, u defined by the Bay Area Air Quality Management all new materials for inspection. District] ❑ Yes 1 haw mad the hazardous marcrlals requiement5 underChapher 6.95 of the Califor. nia Health &Balmy Cade, Sectiom 25515,25533 arm 25534, 1 undenrumd that lime building does not currently haw a unana that it is my responsibility to unary he m:cupanl of the mqummcmawhich muslmmm priorwissuance ofa Cemilcam of Occupancy. Signature of Applicant Date All roof coverings to be Class "B" or better �. water a, 1hhanand,Leal Dam CITY OFCUPERTINO BUILDING DIVISION PERMIT ,(`()NPRAU�"T(1R'11V'k' .4h. T WY BUILDING ADDRESS: PERMIT NO.0 5 0 9 0 218 2622 MARIAN XS NAME: PERMIT ISSUE DATE MARIANIST PROVINCE OF THE . S . 02107/20 06 NE: SANITARY NO. CONTROL NO. ARCHITECrIENGINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH 3O6 LICENSED CONTRACTORS DECLARATION Job Description U 1 Mmby affirm cast l un financed under provision of Chapter 9(commencing Nth Section 7001A.Division 3 of do Bu i.and Prokaiom CoM.snd my license,u e� in fall(a.andaffa" ADD 6922 . 99 ' /REMODEL 14 , 427 . 261 Ueronm�` Comments,- ADD BED/BATH/ENLARGING KITCHEN/DINING RM 111--- ARCHIIECted.pu public CHAPEL & REMODEL THROUGOUT I understand my pta ARCHITECTS DECLARATION k c Licensed Professional ` 3 OWNER-BUILDER DECLARATION +� I hcmby affirm that I sac exempt from the Contactors Uccuc law f0r the `00 following reason.(Section 703 1.5,Business and Profassiuu Cade:Any cityor county $ which requimsa permit in eambuc4 eller,improve,demolish,or repair any structure z ' prior in its issuance.also acquires tic applicant for such permit en rile a signed statement g G that WisliM=dPrommtInthe provisions ofthe Contractor's Licom Law(Chapter 9 Sq.Ft. Floor Area Valuation € (commencing with Section TWO)of Division 3nfthe Business and Professions Cade)at $2937603 E g$E that M u ammpt themfrom and dm basis fa the alleged exemption.Any violation of Section 7031.5 by my applicant for a permit subjects the applicant sea civil penalty of APN Number Occupancy Type not mom than five hundred dollars(WOO). ❑I,u owner of the pmpmy.cur my employcu with"m a tick role mmpenmlon, will do the work and theavocrom is not intended oroffemd fm sale(Sm.7044,BWnev Required Inspections and Profession Code:The Certainties'.Lim.Law does not apply to an owner of q p property,who builds cur imprmvea thcaon,and who does such work himself or through his own employees,provided that men improvements cue not Intended Or offered for We IL however,the building or Improwmant Ice said within one year of completion,dm water. builder will have the burden of proving that M did nm build or improve for purpose of sale. as))R4. , owner of Nn m e property,am exclusively contracting with Hamad cammom rOntma the project(Sec.7004,Busineu and Profession Cade:)The Conuacmrs U. come law does not apply to an owner of proper ,who builds or improws daemon,rod, who contracts for such pmjecm with a conuanor(s)gleamed pursuant an dm Cmarmloes License Law. ❑1 am exempt under Sec. B k P C for this mason !' WO�ENSATION DECLARATION I thereby&loan under penally of perjury om of the following declantiom: I haw and will maintain a Certificates of Came,ro self-insua for Workers Common. anon,u provided for by Section 37M of the labor Cade,for the performance of the work for which this permit is issned. ❑1 his, and will maintain Worker's Compensation Insurance,u required by Section 3700 of the Lmor Cade,for the performance of the work for which this permit is luued. My Workers Campemadon Insurance artier and Policy number am: ' Grier. Polity No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This auction need ant be completed If the permit 4 foram hundred dollars(SIM) or IeuJ I cordfy net In the performance of the work for which On,perm[,is issued.l Ntll am employ any person in my manneWorkers'Compemadon Laws of Cgqtfomia.Dam Amt-LCi Applicant Ld'WWI^tee NOTICE TO APPLICANT:IL after making this omincom of Exemption.you should become subject m Ne Workers Compensation pravisiom of the labor Code,you must .J O foMwith comply with such pmvisiom m this permit"I m dcoed mmoored.Z. CONSTRUCTION LENDING AGENCY [..t 1 hemby affirm that them Is a comunctim lending agency far the performance of p$7 the wok fm which this permit is issued(Sat.3057.Co.C.) Qtartish Name z Landers Add¢as U0 1 curtly that I have mad this application and Mute had the allow information is ly.Fconn"I gree to comply with all city and county ordinances and sum laws totaling m V Wilding conmuction,and hereby suborn representatives of this city to curet upon Im W above-mentioned pmperly for inspection purposes py (We)ague to saw,indemnify ad kup harmless 0n.City of cupcnino&l r cn liabilities,judgments,costs and expo.which may to any way accoue agaiut Mid City U 7 In c.mcc uene of the gumml,of this permit. Ca APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINf Issued by:9 Date SOURCE REPULAnONS VCnuecr -roofs Iguureo ApplicnamData Re 1�� HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will era applicant or future building occupantslow or handle hazudam material Oned by the Cupertino Municipal Cade.Chapter 9.13,and the Health and Safety Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes u - Will the applicam or fuwm building occupom tau equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove It harudnu air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District] ❑Yes I have mad the hazardous materials requirements underChapaerd.95 of the Califor. ole Health&Safety Cade,Section 25505,35533 atu35334.1 undemmnd thulfthe building does not currently haw a mnm4 that it is my responsibility m notify the cocupaut of the requiremenm which muslmmn priorwiauance ofa Comliam of Occupancy. Signature of Applicant Date /. z-c2Y- caner or.uthorimd agent Dam All roof coverings to be Class"B"or better �.