03110093 CITY OF CUPERTINO �
BUILDING DIVISION PERMIT CONTRACTOR INF,ORMATION,r ;4;
BUILDINGADDRESS: TEAM SERVICES INC PERMITNO03110093
R'S NAME: PERMIT ISSUSDATE
LDS 500 FORBES ASSOC 2003
PHONE: SANITARY N0, CONTROL NO.
408) 982-0373
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
is t� to
O O LICENSED CONTRACTOR'S DECLARATION
I I hereby affirm Net 1 em lianscd under provision of Chapter 9(commencing Job Description
with Senion]d c(ec Division 3 of the Busiae••eM Pmfeuiom Cade.end my license is
�mZinmBmmeameer@e'' REVISION--IN HOUSE USE ONLY
License Clava Like
II-- Dam Contractor NO NEW PERMIT ISSUED/ORIG. #03100201
`p ARCHITECTS DECLARATION
<<aaZZ I understand my plans shall he used As public recordist
MLicensed Pmfcss1tard
7
OWNER-BUILDER DECLARATION
2 f 1 hereby affirm that 1 em exempt farm the Comranors License Law for the
0O following meson.(Section 7151.5.Business and Pmfessimis Cole:Any city or county
3$ which requires a permit to construct,alter,irepmse,demolish,or repair any stmnute
iy prior hs its issuance.also requires the applicant rot such permit to rile a signed statement
< that he is licensed pursuant to the provisions of the Comirctur's License Law(Chapter 9 Sq. Ft.Floor Area Valuation $0
2]x2 O (commencing with Section 700a))of Division 3 of the B udness and Professions C.Je)of
i y$ that M 0 exempt thertfrom and Ne basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty or APN Number Occupancy Type
not mare than five hundred dollars($500). P y YP
❑I,As owner of theperany,or my employees with wages As their stole compensation, 32636071 . 00
will do the work end the swnum is not intended or offered for al.(Sec.7044.Business
and Profusion Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and whodms such work himself orthrough his
own employees,provided that such Umprovemenu are not immaded.,offered rorsele.If.
however,the building or improvement is sold within one year of comptetion,the owner-
builder will have the burden of pmving that he did not Wild or improve for purpose of
tale.).
❑has owner of cl property.am exclusively cofessi ns with licensed C aracter's t. / \
came La the es not (Bey.7044,owner
of and property
who
ds or
The
ve%due Character's n
echo Law dcea not apply to en owner of propony who Wiles or improves thereon,or's
who contracts for wch projccu with ac.ntracbr(s)lianxdpursmm to Comer ora \�
LICLMW w.
❑lam tempt undo See. ,BkP�Q r
ORKER'SC ENSATIONDECLARAnO
I hereby affirm under penalty of perjury ane of the fellnloW,declarations:
❑I have and will maintain aCertUOcam of Consent m self-Unum for Wurker'sCompen-
smion,As provided for by Section 3700 of dm Labor Code,for the per(o ormace or the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inurance,As required by Section
37M of the Labor Code,for the performance of Bre work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: _
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm becomocted Bthe permit Isf.rone hundred dollen(SI W)
or kssJ
1 ccnify that in the performance of the work for which this permit u issued,1 shall not
employ any person in any manner an As in become subjects.the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.arer making this CeniFiam of Exemption,you should
become subject to the Workers Compensation provisions of the tabor Code,you mum
'O forthwith comply With such provision or this Permit be deemed revoked.
zCONSTRUCTION LENDING AGENCY
I h.rtby affirm Nat Vert it.construction lamling agency fns'the,pciformama of
WLbe.,it 09]
fur which this permit is issued(Sec.3 ,Civ.C.)
137 Q Lender's Nam.
= z Lender's Address
U Q 1 ccnify that I have read Nis application and sum Nat the above information it
IL F corset I at.to comply with all city and county ordinances and mm laws relating to
OU building construction.and hereby Audience,representatives of this city to enter upon the
4T7 abovo-mcnli...d property for inspection pugwres
gy (We)agree to ss..indemnity and kap ha mless the City or Cuixoda.against ^
h liabilities.judgments.costs and As Names which may in any way accrue against said City / f/
V Z in consequence of the graming u( grrmis
^'
APP
ANT UNDERSTAND D WILL COMPLY WITH ALL NO -POI Issued by: Date
S AT
Re-roofs
urea ' HAZonloscul,19,ARDO MATERIALS DISCLOSURE Da Type of Roof
Will the applicant or fumrc building occupant Bore or handle hazardous mamriel
jd,fiZd1y
the Cupertino Municipal,Code,Chapter 9.12.and the Health and Safely
,OYG rion 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
Will the applicant oruturc building.ccupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hacarenes air cnnmminanu lined by the Bay Arca Air Quality Management all new materials for inspection.
District?
[:3 Yes No
I have rcaddo hmatdt smamriah myuimmenuundcr Chapterh.95ofth.Calif.r-
ria Halth�safcty Ctale,gee s25N15.25533and25334.luWcrsmndth ifthelnuld I,
does not correctly have a etn at It is my rupumin ity m notify tbe Capco, f the
rcments war 'o I.ioateact.raccotreate.r, Signature of Applicant Date
o r a a I nor e agynt rc All roof coverings to be Class "B" or better