05020170 CI'T'Y 01p CUPERTINO '.,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:,,
BBUu.DINC ADDRESS: DPM PROPERTY MANAGEMENT, I eMITNIb5020170
O NEWS NAME: PERMITLSSUEDATE
DOLLINGER DE ANZA ASSOC , 555 TWIN DOLPHIN D? 4r�00 n4 /2o/2nos
SANITARY NO. CONTROL NO.
(650) 508-8666
nRCHITECrIENGINEER: BUILDING PERMIT INFO
BLDG ELEC7t PLUMB MECH
0 0
li o o LICENSED CONTRACTOR'S DECLARATION
U C 1 bunny affirm that I am licensed under previsions of Chapter 9(commencing Job Description
nil
with Section 7WlBof Diviaimn 3of ths e Rusinaand Professions Code.and my license is
full force and effect. X o 5 772 T. I . ADDING WALLS
IM paNnma. _ c��t"aetor 'r REFERRAL REALTY
ARCHITECTS DECLARATION
�i rG e I undpcnend my plans shall W used as public records �-• -x. '-•
OyU
Sou Clamant Profession al
-IOuOWNER-BUILDER DECLARATION f`Irl� aIIl17�
<I I hereby'flim flat
I Ont exempt from the Cnntrannr's Lice®c Law for the LL U
00 following nose,.(Section 7051.5,Business and Prnressions Code:Any city or county
m which requires a permit m c urvrucL niter,improve,demdish,m repair any sbuhum �,�Is f*'as,• . „ „_
Flaprimp,its issuance,also squires the applicant forsuch permit an rile a signed statemcm
that he is licensed pursuant to the provisions of the Centraclori License Law(Chapter 1) Sq.Ft. Floor Areat 7Va'I �(�1000
Jt_y9Fo (commencing with Section 70(YBof Division 3 o(the Business and Pmfcasims Code)or UL-
ars
that M is exempt the¢frnm and the basis for the alleged exemption.Any violation of
Section 7051.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nm mom titan foe bundmd dollars($500).
01,az owner of the propcny,or my employee with wages u their mle compensation, 36610132 . 00
will do the work,and the suucmm is not intended or Orfered forsele IStt.7fk4,Business
and Professions Code:The Conoanort License law does not apply to an owner Of Required Inspections
property who builds or improves thence,end who does such work himself or through his
own employees,provided that Ash improvements are not mended or offered for sale.If.
however,our building or improvement is sold within one year of compleden,the mwner.
builder will have the harden of pmving that he did not build or improve for purpose of
sale.).
0 1,as owner of Ne propcny,am exclusively contracting with licensed conoacmrs to
construct the pmjepl sce.7(raq Business and Predic m Cade:)The Conoacmr's Li.
cense Law docs not apply to an owner mf pmpeny who Wilds or imporm Hereon,and,
who pommels for such projects with a coutnhor(S)licensed pursuant route Contractors
License Law.
❑I am exempt under Sec. ,B h P C for moon
Data
WORKER'S COMPENSATION DECLARATION
46"1 hereby affirm trader penalty of perjury One of the following declarations:
0 1 have and will maintain a Certificate of Consent to self-imum for WorkeesCompen-
.room,as provided for by Section 3700 of the Iabnr Code,for the perfmmance of the
work for which Oris permit is issued.
0 1 have and will maintain Workers Compensation Insurance,as required by Station
37M of the Labor Code,for the performance of the work for which this permit is issued.
My WO kers Compensation�hnnsumn¢carni I end Policy numdhe�r art �'} Z
Cartie( Gp GC Go'^I . y—�-
Policy No.:��
CERTIPICATK OF iUiEMPrioN FROM WORKERS'
COMPENSATION INSURANCE
(This lead.need nal be completed if the permit is from¢hundred dollars(SIW)
nr less.)
1 purify that in the perfummnce of Ne work for which this Permit is issued,I shall not
employ any person in any manner an as to become subjects,the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nis Ccriacem Of Exemption,you should
become subject to the Worker's Compensmion provisions or the Labor Cade,you must
.,2 furthwhh comply widt such provisions or this permit mail W deemed revoked.
zO CONSTRUC ION LENDING AGENCY
F-t I hereby afOrm mar there is a consumption lending agency for the Performance or
R'i > the work Or which this PCMOL Is issued(sec.3097,civ.C.)
!A 0 Lenders Name
D Z Lenders Address
V Q 1 certify mat I haw mad this application and sate that the above information is
(r.,tom^ correct.l agree an comply with all city and county oNinanpes and sure laws relating to
0 building consumption,and hereby outh,ns representatives crisis city anchor upon the
W above-mentioned property fur inspection purposes.
gy Wk,agree to save,indemnify and keep harmless the City Of Cupertino against
UZ inconscsocracecros,cstsOndofthisPswhichmeylnanywayaccmcagainslsoidCity 'IoS
U ,'�' A cPLICA T of the granting of this permit. I 11
^' APPLICANT UNDERSTANDS AND WILI.COIdCWIT .ALL NON-POINT Issued by: Date
SOURCE.REGULATIONS /—
'- ter y n-mss Re-roofs
Signature of Appliant/Counuou r Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant slope or handle hazardous mmenal
as defnpd by the Cupenino Municipal Code,Chapter 9.12,and the Hcalth and Code sedea 25532(a)7
0Yns ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding ocopurn use equipment or dpvipcs which If a roof is installed without first obtaining an inspection,I agree to remove
emit havardom air cnmaminants a defined by the Bay Area Ail Quality Management all new materials for inspection.
D'shlct7
❑Yes No
I have mad the hasamou.c materials requirements under Chapter 6.95 ofthe Califor- / ' ----
msIi.l"SafmyCWc,SOcdtms255B5,25533andU5}.lumCrsundthmif,W Wilding _�_ ,-� tJ _ 0-5div not come Mir have a¢nam,Not it is my responsibility 0 nod ly the Occupant of plc lz �� _ _
mqui mmems which on mat le met prior to ou" aw-'te�nlfirm,of Occupancy.
Signature ofApplicant Date
All roof coverings to be Class "B" or better
Owner or authorimd agent Date