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CITY OF CUPERTINO_-,
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BUILDING DIVISION PERMIT
ICON I 'C'T OR
,INF,�QRMATION:`,
BUILDING ADDRESS:
DEVCON CONSTRUCTION INC
P"""RN®5020090
'73500 CR
'ER'S NAME:
PERMIT ISSUE DATE
THE FORUM
690 GIBRALTAR DR
06Z28/2005
PHONE:
SANITARY NO. CONTROL NO.
(408)942-8200
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
+
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I burr" .(firm that 1 am under provisions of Chapter 9 (commencing
o
h
with Section 7) of Division J off thee Business and professions Code, and my license is
in full to= and effect.
License Clan Lic.It
DEMO (INTER./EXTER. WALLS/FURNACE)
,
Dale Contractor
ARCHITECT'S DECLARATION
1 understand my plans dull be used as public reamer
�/O
Licensed Professional
OWNER -BUILDER DECLARATION
\\
1 Wrthy affirm I am exempt from Om ConuanoYd License Law for he
fallowing moon. (section ?Ion I.S. and Pmfdemols Cult: Any tiny nr county
on
a permit construct, ahxas
which myus t impmsu ore pair any nrvaum
1000
requirestoalter,
u h Permit E
prior m its Issuance, pursuant also mqo the the applicam roe such Pertniuo Glc s signed aulomem
he previsions of the Contractor's LianuLaw (Chapter9
Sq. F[. Floor Area .\ Valuation
(that
commescanud Sction7 M) Division n of the Business andCode) or
(commencing with Section 90nd1
Net the pt on.Any vii
u exempt therefrom and the aper for the alleged exemption. Any violation of
io
Section 703thre by vry applicant fora permit subjects the applicant to a civil penalty of
e
Occupancy Type
not more than fix nunama donors (ssoo).
❑ 1, u owner of the Property, or my employees with wages ss their sale compensation.
will do the work, and the structure is non intended or offered for sale (Sec. ]Oda, Business
and Profecsiom Code: The Co traemr's uaa5e law does an, apply to in owner of
Required Inspections
Property who Wilda orimprows thereon, and who Eoessoch work him adfor through his
own employees, pmvidcd that such impmwmanss sum not intended or offered for sale. If.
however, the Wilding or improvement is sold within one year of completion, the owner -
builder will ban the burden of proving that rte did not Wild or improv for purpose of
salt.).
I. as owner of the rmpart, am exclusively contracting with licensed commues m
co hon the pmjcct (Sec. 7044, Business and Profaxiors Code:)The Comment' 'a Li -
came law does not apply an an owner ofproperty, who Wilds or improve thereon. and
who contracts for such project; with a contra tors) licensed pursuant to the Contractors
License Law.
❑ I am exempt r Sec. B & P C for this Lesson
Data 7 o
WORKEr COMPENSATION DECLARATION
I hereby of ern under Penalty of perjury one of the following declarations:
I haw and will maintain a CertiGcae of Conownuo self -insure for Workars Compere
sation• as provided for by Section 37M of the labor Can, for the Performance of the
work for which this goordt is issued.
❑ 1 have and will maintain Workers Compensation Emma, as required by Section
37W of the tanor Cotic• for the perfarmana of the wart ror which this pcemit is issued.
My Wohcrs Compevalion Touren¢ carrier and Policy number art:
,
Carrier. Poli, No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(This section need not becomplcted if the permit Is for one hundred dollars (SIM)
or less.)
1 ttrtify Lou in the performance of the work far whit' s Permit is issued, I shall not
employ any peRan In any hounel50 aLmnC[OmLS CeI1n the Workers Compensation
Laws of Califorma. Da¢
Applicant
NOTICE TO APPLICANT: If. . hr making omfi am of Exemption, you should
become subject 10 she Worker's Compntsai pmvisions of the Labor Cotic, you most
foMwith comply with such provisions or this Permit shall W deemm revoked.
CONSTRUCTION LENDING AGENCY
I hereby alarm that there is a construction lending agency far doe Performance of
the work fur which his permit is issued (Sec. 3097, Civ. C.)
Lender's Name
'
Lender's Address
1 certify than 1 have mad this application and sate Nn the above information is
cermet 1 agree to comply wish all city and county oNinentts and ante laws relating Ip
building construction, and hereby authorim mpresenutisea of this city no color upon he
d property fon inspection proposes.
lihove-ms,
(We) agree to save, indemnify and keep harmlcu the City or Cupertino against
liabilities, truceo nu,coalsend expenses which may in any way ¢terve against said City
judgments,
udg
m cansequenec of the or This permit.
UNDERSTANDS
APPLIC UNDERSTANDS AND W COMPLY WITH ALL NON -POINT
Issued by: Date
SOUE G ATIONS
Re -roofs
11 6-28'o
argnawrt of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicam or fumm Wilding occupant smm or handic haramous material
de Bond by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety
Sccdon 255314)?
[3 Y. RPU
IV
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to
Will thea scam or building oar ant ase equipment or devices which
PP 6 4uipmcn
remove
us air contaminants u dcfncd by he Bay Arta Air Quality Management
n
all new materials for inspection.
Dist ict'
District' `�w5/,��
0Yes .ty No
I have mad the hmartln , aroarerials requirements under Coupon 6.95 orlhe Califor-
doHealth &Sammy Com.Sao.2SW5,255J3 and 25534.1 umbrsund door ifthe Wilding
docs not currently have a mount hat iti 'y fesparruhitiry m notify the occupant of he
mqui is mnmusp,�a rl5suantturacemEcamorOccurt.
�6
Signature of Applicant Date
_ -e
All roof coverings to be Class "B" or better
Owncr or awhadmd agent Dam