05100100 CITY OF CUPERTINO
BUILDING DIVISION PERMIT COV" tA1W"�T�'►R '��1M�xx(;1 � '''
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BUILDING ADDRESS: a PINN BROTHERS CONSTRUCTIOIS
RMITNo.05100100
.LD745 NDE ANZA BT,V :4 III
R'S NAME: PERMIT IBBUB DATE
BAY COLONY INVESTORS II INV 1475 SARAT
PHONE: SANITARY No. CONTROL NO.
(408) 252-9131
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO EO PLO MECH
�pp LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commcncint
with Section 70110)of Divialan 3.(the Entinw sed Profession Code,and my license is
„ in lull farce and Client. -&-
FJ
NEW CONDO-1, 460
t Z License Class I.C.M
'F Dem J A I��ConDECLAve
qq Iu L t- "yp AR hall W used
DECIA
PLATION- `1 I understand my plana shall M used u public rtenrN
i
o� Unto ud Professional
5 OWNER-BUILDER DECLARATION
1 hcehy,from that I am eacmps from Ne Comoseldes License Law for Ne
:cc Tollnwing..on.(Section 7031.3.Business and Profeem..Cade:Any city or county
let which requires a Permit to construct,alter.Improve.demolish,or repair any aractuse
•Za prior te its issuance.a].uquitusthe applicant forsuch permit ut Ric a signed statement
; C that be is licensed pursuant to the Provisions of the Contractor's License law(Chapter 9 Sq.Ft. Floor Area that
Z (commencing with Section 7000)of Division 3 of the Busincuand Professions Codd or
that ho is attempt themfmm and the bub for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjectsme applicant o a civil penalty of r Occupancy Type
not mart Nan five hundred dollars(MI
❑I.a a owner of the property.or mss employees with wagon As deb Sok compentsNan.
will do du werk,And the structure is not Intended or offered fertile(Sm.]OM,Business Required Inspections
and Profrsdau Cade The Communes L)ceue caw does not apply to an owner of q P
propenY who builds err improv mention,and who does such wog himeelf o though his
ownemplayeea,provided that such improvements Are not intended oroResd for uta If.
however.the building or Mp councet is Sold within one you of cnmpletam.Ne owner-
builder will have the burden of proving that hti did net Wild or improve for purpose of
sok.).
❑1.an owner of the propenY•am exclusively contracting with limned cenuanom In
construct de Project(Sec.7014.Business and Profesdane Code:)The Contractors Li-
cense taw dm not apply to an owner of propeny who build,or improves demon,and
who conuacm for such projects with a contractor(s)granted pursuant to the Canuecsera
Liceoe law.
1 an exempt under Sec ,B As P C for this meson
Dau
or WORKER'S COMPENSATION DECLARATION
WI hereby Mann under peulty,of perjury ore of the following declaradone:
hem and will maintain aCenifteses of Consent to self-insure for WorknesCooper.
sation an provided for by Section 3700 of Ne labor Code,for the Performance of the
wterr which this permit is issued.
1 have and will maintain Workers Compeuatlon Ir11oatce,As required by Section
3700 of the labor Code,far the pufarmance of the work for which this pnmtt b issued.
My Worgetg tape anon btwret�arier and Polity ryenp5fafg,�� p„
Grier. r/CY�Ai� Polity FROM
Q4lORKERL ' !L
CERTIFICATE OF COMPENSATION
OS FROM WORKERS'
COMPENSATION INSURANCE '
(Thuuctiot recd not le cmmpletul if the permit Is fomes hundred do0ars($1001
or Ria.)
I certify that in de performance of the work ro which thio Permit is issued,I shat)not
employ anyperun in any mannerso u to become subject to de Worberr Compensadon
LA"of California.Dau
Applicant
NOTICE TO APPLICANT:If,alter mMent this Celli iesse of Esempsion,you should
become subjem to the Wohers Compcudon provision of tho labor Code you mice
Ofordwith comply with such provisions or this PComL 111111 be domed uvnked.
ZN CONSTRUCTION LENDING AGENCY
E► I hereby affirm that dee Is a construction Innding agency for the Performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
QLandnes Name
z Lander,Adaa
n
V 0 1 cenifY that I have mad this application and feu du the above information is
D. f'" coyest 1 agree to comply with all city and county ordinances and sum laws relating 0
DU Wilding construction,and hereby auNome rtprtun11uvcs of this city tocnune ger the
W
show-mcnuuncd property for imKcuon popous
Qy (We)agree a save,mdcmmfy and keep harmless the City of Cupertino agaiut
nFi W liabiliti.Ajud Weosu xpeues which mass in mss way accrue atuulseid Citylimr+9
V Z APPLmICwne U ERST DS AND WI COMPLY WITH ALL NON-POINT Issued by: Dale
SOURC EG
OF
w`��
'! Re-roofs
Sitnatur App sesnuCanuxwr Dau Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the.1,141.1 err None bulldhtg o cupantatoc or honest.hamohns macs!
Bond by the Cupertino Municipal Code.Chapter 9.12.and de Health and Safety
.Section 255324)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yca Noe
Will the applicants or fume Wilding occupant use cquipmcot or devices which
If a roof is installed without firs[obtaining an inspection,I agree to remove
emu hvvdoua air commonts as fordy d
be Bay Ares Air QuatItY Mangcmcnt all new materials for inspection.
District?
❑Yat u
#g0w
au. 4 uiremeAmun der ChoParG95oftheCalifm-
do at it i 25 S uu12s534.I an@ Cry the up [ofling
heJoat Is b respanilbility m netify Je acupant of dureq arm nf.CMFI aIOccupacy. Signature of Applicant Date
-17-0A All roof coverings to be Class"B"or better
Ownef o auNamad sScm Dau