04100070CITY;OF CUPERTINO .. - —' ..
�v �z}: 7 � x`M j 11`
BUILDING DIVISION' PERMIT
431���"''`w`^+`'W
BUILDING ADDRESS:-
DOUGLAS ROSS CONSTRUCTION
PERMIT NO. '
NC '04100070.
OWNER'S NAME:
LNLO 'EQUITIES
.. . _ ._ --.. _ _... _ - -
Q09 RT_
PERMIT ISSUE DATE".
NE: -
-' --- ^' - --- --
SANITARY ftIROLNO.
ARCNI713CDENGINEER:".
'..
- BUILDING PERMIT INFO
-
BLDG.' ,ELECT PLUMB MECH
: LICENSED CON RACMR'S DECLARATION
JobD05CTlptlOn
I hercby uffirm that lam licensed und.r pmvisiom of Chapmr 9 (commencing
-
with Section 7000,tif Division 3 of NC Business and Pmfcaaions Code.and my license is-
Liicenaeeiassserves Lic#
REVISION --WALL FOOTING
Dam - Cuntmmnr
NO NEW PERMIT ISSUED ORIG. #04050174'..
- " ARCHITECTS DECLARATION
1 understand my plans shall he used as public mcorda
_
.•
Licensed Professional
OWNER -BUILDER DECLARATION
r "' '
'I hereby affirm Nal 1 am exempt from the Convector's License Law for the
.. -
Following means, (Section 7031.5, Business and Professions Code: Any city or county
whish rtquircs a Permit m wnstrua, eller, improve, demnilxh, m rtpw, any ulrunure
prior m its issuarmc, also requires rim applicant our such Permit to file a signed statement
that W is licensed pursuant m the provisions or the Committers License Law (Chapter 9
3q. Ft. Floor Area,
-. .. Valuation -. .
(commencing with Section 7") of Division 3 of NC Business and Pmfcssions Code) or
_ I„ -s it - _
that he u exempt mcmfrom and Ne bash for rile alleged caemption. Any A.Imms of
-.
..
APN Number
- Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not mom Nen live hundred dollars ($500). .. .. -.
.'
❑ L as owner of W NopertY. ar mY cmPloycm with wages w timiraole compensmlor.
00 RequiredInspect
will do thewod. and the Npctum ianminnwhol roRered retard. (See 7044, Business1620084.
and Professions Code: The Contr'actor's License Law does ant apply m an owner of
-
�'-,
property, who builds onmprows thereon. and who doessuch workhimselforthrough his.'..
�,__ ..:�u,r:.'- -w ;. -ti _ ,.. y-. „_`•��,y..,r-f•+s„.,
.we employees, provided Nm such improvements am not Intended aroaered forsale If
however, the budding or improvement is sold within one yew of completion, the owner-
-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1. as owner of the property, am exclusively convecting with licensed connection to
-
construct the project (Sec. 7044, Business and Professions Cade:) The Convector's LI-
-
mume Law dose not apply man owner orpmpeny who builds or improves the orm, and
• -: -.--, - ... - - --- - - ----
whocontractsforsuchprojectswithacommcloos) licensed pursuant to the compactors
License Law.
OIwn t oder See. .�/& C(u q
Owner
WORKP.'S COMPENSATION DECLARA N w
ereby offirm un der penalty of perjury one of to following Iwede
..
IIs -].ad will maintain a CcrtiBcam of Consent m self-usumfor Wurker'sCompen-
sation, provided for by Secdon 3700 of me labor Cod., forme ped..enm of the
workf which thispermitis issued.
❑ 1 haw and will maintain worker's Compensation Innerence, w required by Section
3700 of me Labor Code, for the Performance often work forwhich this permit is issued.
. .
My Worker's Compensation Insurance carrier and Policy number em:
Cartier. Policy No,:
CERTIFICATE OFEXEMMON FROM WORKERS'
COMPENSATION INSURANCE
- -
(This section need not be completed if the Permit is furore hundred dnilem(5100)
nor less.)
,
I coolly that in the Performance or the work for which this permit is ismed, l shall not
employ any person in any manner an u to become subject to the Workers'Compensation-
Laws of California. Dam
Applicant-
-
NOTICETOAPPLICANT: IL after making this Compose of Exemption, you should
become subject b the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions on rola Permit shell he Lamed rtvnkcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Nam.
Lender's Add.,
I certify that 1 have mad this application and sum sen the above information is
- -
moves. I agree to comply with all city wid county omrounces and arose lam mining to
- � '
building conawction, and hereby authorise mpmeartaut. of this my umm,tipon the
- -- - --'-' - "”'
ahave-mc m mad property for impaction purposes.
,
,::):!
(We) agree m save, indemnify and keep hornless the City of Cupertino against
liabilitim,judgments, coats and expenses which may in anyway acerae againsuaid Lily
j
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. -
Re -roofs
-
Type of Roof
Signeum of ApplicaHAZARDDate
HAZARDOUS MATERIALS DISCLOSURE
O
Will the applicant or forum building occupant store rehandle hwardous materim
as tlefined by the Cupertino Municipal Cale, Chapter 9.12, and the Hcahh and Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed. -
OYes ❑Ne
OilitWill
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or future building occupant use equipment or devices which
Im.mous air conuminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
'
❑Yes ON.
1 have mad the the Califim,
nia Halm&SafctyCodc,Scedons25505,25533wd25534.lun&nwdthuiflhe Wilding
docs not currently have a knot that it is my responsibility m mery the occupant of the
requimmcnu which must be mel poorw issuance of a Ccnificak of Occupancy.
Signature Of Applicant Date
- " All roof coverings to be Class "B" or better
owns
lir eammrixatl agent Dam