05020012 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT �ICONTRACTOR^INFORMATION:.i
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BUILDING ADDRESS: """b5020012
"NO.,50 2 0 0 12
ourER•S NAME: PERMIT ISSUE DATE
SUNNY VIEW LUTHERAN T-To R.
NO.
ONE: SANITARY CONTROL NO.
ARCHr1EC(ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(� 0
Loo LICENSED CONIRS DECLARATION
1 Mosby affirm In.,1 am licensed
underumkr provisions of Chapter 9(commencing Job Description
with Satiun 7akD of Division 3 of Ne Business end Professinm Coytic,antl my licpnm is
LittvxCissmeerrea'.Al Lic bsgyy• TI--3 OUTLETS/ 12 ' PONY WALL/
:o veto Contactor Swad�
ARCHITECTS DECLARATION CHANGE FINISH/FL./LIT FIXTURES
y,w-
gg� l understand my platu stall he used as public records P CONTRACTOR: SANTA CLARA VALLEY CORP.
Tatou
�trp r^ Licensed Professional
3 OWNER-BUILDER DECLARATION
Z 1 hereby affirm that 1 am exemia from the Commcmr's License Law far the
O O following reason.(Section 7031.5.Business and Professions Code:Any city or county
x m 6� which requires a permit to emm num,alte,improve,demnli h.nr repair any .arm
to
Z�, prior to im issuance,also requ res the applicant for such permit to file a signed suement
�t0
that he is licensed pursuan,tolm provisions of the Conmcmri Limns Low(Chapter 9 Sq.Ft. Floor Area Valuation
m1- (commencing with Section 7")of Division Sof the Business and Professions Code)or
a $ that he is exempt therefrom and Out basis for the alleged exemption.Any violation of $35762
Sccuon 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of ane APN Number Occas Type
not mom Nan five hundred doll.($!5M). P Y YP
❑LasowncroftM preprrzy,army cmploycu with wagesu deirwlccrmpenalohm,
will eo the work and tM swctme is not intended or offered forsake(See.7(344,Business
and Professions Code:The Conlsxmowner rs License Law does not apply to in oer of Requirred Inspections
property who Imidsor improves lemon.and who doessuch work himselfor through his �_ 1 \ rs
own employees.pmvidcd that such improvements are not intended oroffeme Intuit If.
however.are building or improvement is sold within one year ofcompleuon,Nc owner.
builder will have the burden of proving that M did not build or improve for purpose of !
f~
axle.). .i.1
❑1,as owner of de pmpeny,am exclusively contracting with licensed contractors to <
construct the project(Sec.]Ota,Business and partitions Code:)The Contractor's Li- vfy
cense Law does not apply 0 an owner of Doric.who Mild,or improves thereon.and, M,q4
who cone us for such projects with a conuactor(s)licensed pursuant to the Contr¢m/s /f I
Lkp
cnseLaw. �sr� ? i 4
El I am exempt under Sec. ,B&PC for this MixonDam
1307WWORKER'S COMPENSATION DECLARATION
1 hereby aRnm under penalty,of perjury arc of the following dcclar ationc.
haw and will maintain a Certificate of Convent to mlf-insum for Workces Compim
n,az provided for by Section 37W of are labor Code,for the performance of the
for which this permit is issued.
have and will maintain Workch Compeusation huuntax,as required by Section
of Ne Labor Code.for the performance of the work for which Nis permit is issuedWorkrelc gppemadon tInisu�nna carrier and Policy nu4mberamyier: aTi+h. rwa+r PolicyNo.: p _jn i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section reed not M completed if Ne remit is foronc hundred dollars(SIM)
cur Itss.)
I cenify that in the perrmarxnce or the work for which this permit is issued I shall not
employ any person in any manner in as to Mmme subject o the Workers'Compenutian .
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation pmvisious of IM labor Code.you must
.Jz forthwith comply with such provisions or this permit mail M deemed revoked.
zCONSTRUCTION LENDING AGENCY
[-+ Imothy.M.Nat there iso convection lendingagency l'nr the performance of
a
the work lar which this permit is issued(Sec.3037,Ci¢C.)
W Under's Name
ID z Lender's Adl
U mss
/
U Q 1 certify that 1 have read this city
and Lioncoup and sum that the abase information relating
is
W U correct 1 agree m comply with all city and county arraim of and sum tows r upon
e
�U &NOvWilde-gcationdtion,and hereby wNoriampreunudsesof Niscity toenur upon Ne
�W shove-menuunWpmpeny for inspection expenses
purposes
H6. (We)agree to save,indemnify and keep harmless the City of Cupertino against
h incoitiesurnre f arecommand of this csmay in any way accrue against mid City r /
U Aconsequence of UNDERSTANDS
of this Permit.
w.
sou REGard
UNDTIONS.NDS ANO WILL COMPLY WITH ALL NON-POINT Issued by: Dale z'
� I
2 w l+f Re-roofs
Signawrc o AOD rc
HAZARDOUS MATERIALS DISCLOSURE Dam
Type of Roof
Will the applicant or future building occupant store or handle haraalous material
as defined by the Cupertino Municipal Code,Chapwr 9.13,and the Health and Safety
c.Section 25533(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yea l&No
If a roof is installed without first obtaining an inspection,I agree to remove
Will tar applicant or rets a Willing occupant taw Area
Air Qu or levans which g
lDi,trilL'
t hanrdous air contaminants u Jcfincd by Nc Bay Arta Air Quality Management all new materials for inspection.
❑Ycm b(No
IhawacedthchavallousmaterialsmquimmcnuunderChapwrQ95ofIMCalifonHeslth&SafetyCode.Scc=m 5O5.2533am 53.lundcnundth ifthc building
s rot currently haw a cream Nat it u my responsibility m rmtiry Ne occupent or due
irements whie aN ba met poor to room=of a ccmIDeate of Occupancy. Signature of Applicant Date
�Qoraua �g 21s am All roof coverings to be Class"B"or better
Owner or tut�i g�� Dare