05110050 CITY OP CIJP ERTINO -
R1JILDlNCDIVISION PiERMIT -C6NT1LACT0RINFORMATION:
BUILDING ADDRESS: DOLLINGER DE ANZA ASSOCIA Mrr ND.05110050
160.1 DE ANZA BLVD ff 11.8
-..R'S NAME: PERMIT WOE DATE
DOLLINGER DE ANZA ASSOCIAT S 5
P ONE: SAMTARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONI RACfOR'SDECLARATION Job Description
I Immby ofli m that I am licensed under pravisioa of Chapter 9(commencing
with Section]CIN))of Division l urine Business it profeuiasn Code,and my license u
nrmlfameanderreap TI-3 OFFICES (ELECT. MECH)
j License Class Lic,p
__ROINqq ARCHITECTSDECLARATION
2< I understand my plans shall be used as public records
)yU
xaH LiccnuJ Pmfesxiowl
3 OW NEnd CmDER DECLARATION
<2 I hereby affirm tom 1 t. exempt from Ne Gonias Co License Law(or the
p o following mann. Peron t IDl1.3,Business and w.de inns Code:Any city m caumy
1:� pooch mquita a permit re construct,the alter,ire prow,deermitt care a signed
igany nmctum $149061
061
-16 Prior m its i omed ,also nt to the the applicant dor such perm's License
se Law(Chapter
9
titammecansed enation 7001 pmvimonsn of the B acwrxnianclaw Qnapter9 Sq.Ft. Floor Area Valuation
E o (cat be Is(commencing with Section of Division)of the Business and Profeuinns Aide do or
i Net io u exempt any applicant
li and the oasis for Ne alleged Bampton.Any violation of
Semon 7031.3 five
ury applicant fora permit Subjects;the applicant res a civil Pcnahy Of Occupancy Type
not mart than Ew hundmd dollars(5500).
Lo the work.
the property, myemptoym wr Offered
their tale campenain.
will Pr Newark Code:and StructureheCoic timnot's Licennded se
raw dos act apply he im, victim Of Re UITed_In5 ectlons
and erry who
Code:The vers house 'a License Law does rot apply lf rt rough is q ` "P�
own enyphnbuildsorimprovesthimpoand musamsormanersuchwork himmlfalor through his JCCCIII///lll/�
however,the
or improvement rsueh improvemeouare not ear of cmpecrc,the o der- n
however.theaved a, anproviissalde diinot year or completion,the owner-
.Is), will have We burden of paring that he JIJ not Wild or improv for purpose of
I,as owner of the property,am exclmivclY contracting with licensed souse on In Atoll
contused Ne project(Sec.B)..,Basin.and Prooddrom Cars:)The Canuamor's Li.
,Co.law does rot apply to as owner of proporry who builds or improves Herron,add,
who contacts for such projects with a eantmopulyd licensed Punta..he the Contractor's r
Lkense Low,
lam exempt under See ,B k P C far this matin `/ Jail 'A, f.
erDau
AI' ra y
WORKER'S COMPENSATIONDECLARATION
1 hereby affirm under penalty Of perjury nu of the following drohmaLions:
❑ I ham and will maintain a Ccnlfreaurf Comenuoself-insum for Workers Ccat
xminn,as provided for by Section 17W of the labor Code,for the performance of the
walk for which this permit is issued.
01 have and will maintain Winkles Compensation las.ranfe,u required by sector,
)]W of the Labor Code.far the petfarmmce or the work Our which this armor IS issued.
My Workers Compensation Iran...artier and Policy number Sp:
Cartier. SIrJ'IC��MOPX&them Policy No.: l25.5"13
CERTIFICATE of EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nominal hecomplemd if the permit o f crone hundmd dollars(SIM)
r leas)
1 cenify then in the perfanwnce of the work far which this permit is im.ed,1 shall not
employ any petun in any manner so as w become Subject o tic Worken'Compensation
laws of Glifomia.Data
Appllcant
NOTICE TO APPLICANT:If,a(mr making this CeniCc.te of Exemption.Yrm should
become subject to the Worker's CamPewtion previsions of the lahnr Cade,you mar
7 forthwith comply with such provisions or this Permit shall he deemed minutes.
z'O CONSTRUCTION LENDING AGENCY -
(-+ Ihereby affirm that then is a Construction lending agency for Ne perfornmeat of
tY the work fur which this Permit H issued(Sec.)09],Civ.C.)
ft7 Q Lenders Name
4 Lender's Address
U Q 1 certify that 1 have read this...Hamm and out Nat the above informal..is
!L P-s correct.I agree to comply with all city and county ordinances and Strait laws totaling to
0U building Construction,and hereby amhorim repressmanwos of this airy to enter upon the
Lei ahavc-memioned property fon inspection whichpurposes.
gy (We)agree m save,indemnify and kap harmleu the City a(Cupcnino agairut
Lei in consequence
costs and of this torrid, may in any way seas agaimtmid City
U z A PILIC NT of the granting of Nis permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -,0 (7—
SOUR EREGULAT�Iq�S.
lA,(1 AR) 1n= �l Re-roofs ��'r�a"k�.
S!,roilim ofAppl amCm¢mctor 0 Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W II the applicant or forum building. .,.at sloto or handle hatardom material
eMed by tic Cupcnino Municipal Code.Chapter 9.12,and the HaaWt and Safety
Section 23512(.)? U/1.
/� All roofs shall be inspected prior to any roofing material being installed.
C3 yes l/No
Will the applicant car future building Occupant useOquipmcnr or devices which If a roof is installed without first obtaining an inspection,I agree to remove
1,ia
t har.nlmu air comuminanu az dctincd by the Bay Area Air Quality Management all new materials for inspection.
uicrt ,_/
C]Yes �N
1 have read the haardoas mitedab requirements under Chapter G95 of the Califon
He iltr&SafetyCode,Sato.25NI3,15511 asW 2351St.I understnd Nutsifthe building
s nor currently haw a mnanL that it u my responsibility to firmly the aceupmt carNe
virements wan must be ren priorwissuancc a/a Ccrtifai it xupmat.� Signature of Applicant Date
pl DOate. AI I roof coverings to be Class"B"or better
Owner or au hrriud ascan