05100103 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CUI',IITRAC' I'QR TNF(?12MA.TI01!) ,-%
� MR ND.
BUILDING ADDRESS: PINK BROTHERS CONSTRUCTION " 05100103
l
R'S NAME: PERMIT ISSUE DATE
BAY COLONY INVES 475 S
PHONE: SANITARY NO. CONTROL NO,
408) 252-913
ARCHITECT/ENGINEER: BUIIDIN0 PERMITINFO
BLDG EO PLO MEOCH
O� LICENSED CONTRACTOR'S DECLARATION Job Description
ti�F{ I hereby anlrm that I am licensed under provisions of Chapter 9(commencing
E wW Suedan70f10)afDIA.m 3 ofthe Busineea and Profumuns Cade,ad my license is
N in fall tome and B s {-- . NEW CONDO-1, 178
Z Licenae Clan Lk.N
y Dasa Contractor
7 -D'r-rte"
ARCIIMCrSDECLARA1ioN
I i udenund my plans shall W=it as public rtords
a6
:pN Limmed Professional
1H OWNER-BUILDER DECLARATION
1 batch,afB(m Nn 1 am wrap,frene toe Con ommes Ucenw Lew for me
1
:00 following moan.(Sudan 703 1.5.Business and Pmfessium Code:My city ser county
1$ which requires a permit to eonsuue4 Aller,lmPruw,demolish,ser repair my sonoture
MetPoorxitsiensedpaiorcquiMeMc,pplie.fMrmchpcnm'1licnseIAdsukmcm Valuation
< mn hit is licensed ISUAdpuroanuoruds,asiamaf Me Con permitorite alaw(CMptent Sq.Ft.Floor�Aea
$ (canmesming with Section 7")of Division J of me Business and Profassiona Code)or
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that Ins Ise uempt Memfrom reit Me bask fu the alleged exemption.Any viola l of
Section 7031.5 by any applicant for a permit objects the applkent M a civil penalty of J AP14 MiffiftIr U 0 Occupancy Type
not mom than RYC hundred dallare(S5011).
❑I,as owner aftie pmPeny,m my employees with vnges u their ole campemmum,
will do theviork,and Me Inc.kanlinundedm.111cred rmsam(SCC.7014.Business Required Inspections
and Prermajons Cada Tim ConnacbYa License Law doe,not apply in as owner of 9 P
pmpeny who builds or I mpmves maroon,end who does such work him,elf ar though his
ownemployem,proWded Mmuch impmwmanu are not intended aroeened for wale.l(.
huwewa the building or Improvement is mid within am year of completion,the owmr-
holdu will have site human of Proving that he did Out build u Improve far purpose of
ok.).
❑I,u owns of the propmy son euivaively contruvng with licensed con9mton b
comtruct Me Project(Sea 70".T uaines,and Professions,Cade:)The Careamme,U.
cane law ares not apply to an ow+wr of property who builds or improves Meman.and.
who contracts for such Projects with a eonuutor(e)Iiamed Parmot m Me ConuuloYe
Licence law.
I am umap,under Sea ,B B P C far Mk mason
Dau
WORKER'S COMPENSATION DECLARATION
I hereby afasm under penalty of perjury one of the(allowing declarations:
�1
have and will maintain A CemRcom of Consent to self-inmm for Worker'sCompen-
ae.ian.u provided for by Section J700 of Me labor Cade,far me performance of the
arVor which this permit k issued.
QI haw 11 main Worker's Compensation Insurance,u martinet by Section
J700 of the perfarmma of Me wart rat which this permit is Issued.
My War t carrier and Polity, rare:Up
w
Cam Policy No 7
CERTIFICATE OF EXEMPTION FROM WORKERS'
me,.5 COMPENSATION INSURANCE
(ITusedm nasi oat eecompletd ifde permit k foram hundreC aollan(51007
or las:) '
1 eenlfy that in me performance of the work for which this permit Is imed.I"I not
employ any person In any manxreo as m become object to the Workeri Compcalmlion
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cerarinte of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Cdc,you mat
.JO faemwith comply with Such provisions or this permit hall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1•" I bemby afrina that mem k a e m tmetinn lending agency for Ma perfannamc of .
the work for which this permit is issued(Sec.3097,Cin C.)
6Wi Q Lender's Nanta
=z Lemice,Addaee
U Q 1 canary Mat I haus mad this application ask Sum Mn Me show Information is
II. coned.I agree in comply with all City and county ordinances and sum Ions relating W
QU Wilding construction,and hereby authorim mpmmnutives afthis city to enter upon the
r 4 .have-mentioned pmpersy for inspection purposes.
(We)agme to saw,indemnify and keep harmless the City of Cupcnino against
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limilions,juditnorus.ccom smile.picoms whit .,in any way acuuc against mid City
L)z in usmequ pain o Me gran of ais perm
^ APPLICAgry •R IDS AND Wit COMPLY WITH ALL NON-POINT Issued by: Date - /?—a
SOURCE B� ) . 1126
Y Re-roofs �---�
Signuu fApp =Ucfon mor Data a of Roof
HAZARDOUS MATERIALS DISCLOSURE •)p
Will do applicant a future building occupmesoon or handle brumdons material
deRoad by the Cupertino Muni' e1 Coe.Chapter 9.13,and Me Health and Safely
Section 35532(s)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye a
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future Wilding Occupant use equipment or devices which
emit hanrdons air commumets eRnd by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Nr
w mad Me ha��3333{{yyyVddddonsmatoriak requirementsunder Cha puri,95af Me califor.
nu IthkSatetyCa tions255D5.255 arW7S53d.1 umknund Matifthe Wilding
not •a ly Ie11ml Mal ilk reepontlMllty m MG(Y me OCCrpml n(Ihe
m 1rem s n Vuubemdpriorm' uofaCcrti0ca�py�%cupancy� Signature of Applicant Date
0 runumadxcOegept OP 77 Dats All roof coverings to be Class "B"or better