05110111 CITY or CUPn;M INO -•� 3 F 1 -
BUILDINGDIVISIONPERMIT 4cowCJ0R1PT110R1VIATiQN
RUR.DINGADDRESS: ATLAS PELLIZZARI ELECTRIC ff�ffND"05110111
1.0101 N DE ANZA BLVD
'R'S NAME: PERMIT ISSUR DATE
MOULDS 500 FORBES ASSOCIAT 5450 HOWLAN
lE: SANITARY N0, CONTROL NO.
(650) 364-1204
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i00
LICENSED CONTRACTORS DECLARATION lob Description
1 hemby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
U with Section)fl(Nq of Division7of Jle Ousinen dPrufessiun.'Gnde,entl my license is
mmnmm attnarraC \0 �S�( REACTIVA. PERMIT #04110161
a�Z
Lice re us Lic.X
,k.c add Camrmmr 1 NO NEW PERMIT ISSUED
e t�s ARCHITECTS DECLARATION
< < 1 tindersand my plans shall be used n public rtcnrd,
:Ei
Licensed Poressional
OWNER-BUILDER DECLARATION
<i 1 hereby affirm that I am exempt from the Contractor's License Law for the
❑O following reason.(Section 7113 I.S.Business and Professions Code:Any city or county
<m which mquira a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issumcc,also mluires the applicant formed permit to Rlc aligned statement
< that he islicensed pursuant tn(tic provisions nf[he Contractor's LicenseLaw(Chapter 9 Sq. Ft. Floor Area Vali 500
u�Q (coin returning with Section Mill)of Division 3 of the Business and Professions Code)or
that he is en:mpl Iltcrefmm and the basis for the alleged exemption.Any violation of
Scelion 7031.5 by any applicant for a permit subjects the appluarm to a civil penalty of APN Number Occupancy Type
nor more that Rva hundred dollars($500). 3 2634071 . 00
❑1,as owner of lite pmPcny,or my employers with wages as thelrmle compensation,
will do the work.and the suunure is nm intended or offered for sale(See.7044,Business
Old Professional Cade:The Conuanors License Law Jars rot apply to an Owner of Required Inspections
pmpeny who builds or imprnvo thereon,and who dooai ch.,it himselror though his
own employees,D.viddd Nat such improvements are not intended or offered forsole.IL
however.the building or impovemem is sold within one year of eampedon,Ne owner,
builder will have the burden of proving that he did not build or improve for puM=or
sale.).
0 1,as owner or the pmpeny,am exclusively contracting with licensed Contractors in
colOnoul the project(See.7064.Business and PrnfeSalaRi Code:)rue eontractar's LI.
metre Law docs not apply to an owner or property who builds or impose thereon,and
who commca for such projects with a contranDKU banned pursuant te the Contractors
License Law.
❑I am evemPt under See ,08 P C for Nis reawn
r Dale
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury one of IM fallowing dalarmims:
❑ 1 ha+c and will maintain a Ccnifin a of Consent m self-insure far Workers Compen-
as I..,as Provided for by Section 37M of the Labor Code,for the performance of the
mkk for which this permit is issued.
I have and will maintain Workers Compensation Insurance as required by Section
3700n(Ihe la qqr Cale.for me Performanceofthe work far which this permit u issued.
I Workers rfmpeCmaup`p)Insup.ce Cartier and hii,
Cartier. >h T( r11LP Poll,No.:���s `�O"r>`�aa
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one hundred dollars(Slot)
less.)
I cenily that in the fe,fnrmonec of(]in work for which this Permit is issued.I shall not
employ any person In any manncran as it become subject o the Workers'Compensation
Laws of Califomia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ceniffen m of Exemption,you should
became subject to the Workers Compensation provisions.1 00 Labor Code,you must
.J Q forthwith comply with such pubvisiors or this pormitshall M deemed mvoked.
'z� CONSTRUCTION LENDING AGENCY
[r l hereby affirm Nal them is a construction lending agency for the Performance of
C' > the work for which this permit Is issued(See 3097,Civ.C.)
US lender's Name
Z lenders Address
U 0 1 minify that 1 have read Nis application and solid Nat the above information is
U, f-^ cancer 1 agate m comply with all city and county ordinances and slam laws relating to
0U building eensuunion.and hereby mlhmlm mposenoltivea of this city to enter open thc
� a above-mentioned Property ter inspection purpases
(\VC)agree to save,indemnify and kap harmless the City of CupcnlnD against
FrA liabilities,judgments,casts and expemrs which may in any way attrue against said City
U in cuosquenee of the granting of this permit.
^ APPLICANT UND STAIN AND WILL COMPLY WITH AL NON.POINT Issued by: Date
SOURCE 0.EGU S. f ��
���—/ r,7 Re-roofs
Signature or Applicausticontodlelor D�S¢
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the a Cupertino
err forum building e.Chapter
stere err handle health anmaterial
cfined by the Cupcnina Municipal Code.Chapter 9.11,and to Health and Safety
c,Section 15532(aR All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑Nu
Y/RI the applicant or future building occupsnt use equipment or devices which If a roof is installed without first obtaining an inspection,l agree to remove
I
l hil on nus air mntaminnla as dc0ncd by the Bay Area Air Quality Managcmcm all new materials for inspection.
oin?
❑Yes 0 N
I have mad the haraolnm materials requiremenu under Chapter 6.95 of the Califm-
lahh S SbryIy Cnde,Section 155(15,2550 and 25534.1 undenund the if the building
s not cuncmly have a Coen drat't)s my rnponsi hility m notify the acupml of the
mquirend hfebmnslle.t PrirbrissumceofaCcrdOnteorucupmy./ Signature Of Applicant Date
Own11 oratildbulAxod agent Dam
All roof coverings to be Class "B" or better