05110124CITY OF CUPERTINO'
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FORMATION �'�"
BUILDING DIVISION PERMIT
m,CONTRACT�OR4N,
BUILDING ADDRESS:
0-1'10 STR17RNS ("REEK RT ITT)
DOME CONSTRUCTION CORP
PERMIT"°' 05110124
OWNER'S NAME:
PERMIT LSUE DATE
SYMANTEC(GROUND
E:
SANITARY NO. NTR
COOL NO.
415)641-0800
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 botchy affirm that 1 am li¢nrcd under provisions of Chaper 91. meneing
with Section 7")of Division 3 of the Business and I'miessiurs CM1 .1 ken. is
in full force and affect. _
REVISION--REVISE TUNNEL CORRIDOR &
License Class Lim. N
Damy Contractor
PARTITION PARTITION DETAILS/ORIG. 05080048
NAR ON
ARCHECIsDECL
I understand my plans mail W used as public rtcords
NO NEW PERMIT ISSUED
Licensed Professional
OW NER-BUILDER DECLARATION
1 hereby efamn that 1 am exempt from to Conuacmrs License Law for the
following won. (Section 7W 1.5, Business and Professions Code: My city or county
which requires a permit to emnwucs alma improve, demolish. or repair any structure
prior to its issuance. also requires thou .ppi and for such Permit an fill.signed stammcnt
that hcu licensed m Nc Ne Comnmme. Lice. U.(Chop¢r 9
Sq. Ft. Floor Area
Valuation
pursuant provisions of
(commencing with Section 7000) of Division 3 of the Business and Professions Code)w
C
$ 0
that he u exempt therefrom and the basis for the alleged eaereption. Any violation of
APN Number
Occupancy Type
P y YP
Section 7031.5 by arty applicant for a permit subjects the applicant in a civil penally of
Wes es live huedod dollars (M).
Q I,um=otu pmperty.wmymaploymwiNwMw Ne wlecampemuan,
-
Required Inspections
will do thework, and the met.. is roti umalmiaraRerad forsale (Sec. 7014, Busiress
and Profession Code: The Comuacmes License Law dm out apply 0 an Owner or
property who Wilds or lmpmvu thereon. and wh.d.suchwoh himm]for through his
Own cmplmym, provided that such impomments are notinerdW orotrered forsake If.
however, Ne building or improvement is sold within arc year of oompkuon the ower-
builder will have site buNen of moving that he did not Wild or improve for purpose of
ssk.).
Q 1. u owner of the property, am exclusively contracting with 0claxod contractors In
cmwoct die project (See. 7064. Busismv and Pretensions Code:) The CaotraemYs U.
came Law dm not apply m an owner of pmpenywho Wilds or impmves therton. and.
who contracts for such projeaa with a ernuanor(s) licaned pursuant to the Conuanafs
License U-
aw.Q'.mmmtprumda
0 '.mmmtPnmvdkaSee •B$PCrmme...
Own" Data
WORKER'S COMPENSATION DECLARATION
I hereby atnnn under penalty of perjury one of the fallowing decimations,
1 have and will maintain a Certificate of Consent wlf-insurt for Wortcra Cmmpen-
section, u Provided for by Smetion 3700 of the Labor Code• for the perf omm of tie
work for which this Permit is issued.
01, efs Com nsuion Insurume, as r�vired by Section
1 have and will maintain WoIg"
J]00 of the labor Cede, Tor me pcdo fthe wah far which Nu permit int issued.
'
My Workers Com/p�envuon insuran¢ a and Policy number arc:
Cartier. 9ci-ts^ Palley Nsr::
/CERTIFICATE OF EXEMPDON FROM WORKERS'
COMPENSATION INSURANCE
,
Chris cert.. coed not be completed if tie permit is formic hundred dollars (5100)
or less)
I certify that in the performarmc of the work for which this permit is issuc4l shall not
employ any person in any manner w as m become subject retie WorksCompmadda
Laws of Califomia. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you should
become subject an the Workeri Compensation provisions of me Labor Code you mum
roMwith comply with such Provisions w this permit shall be deemed emmited.
I
j CONSTRUCTION LENDING AGENCY
1 hereby arrnm that then ts a construction lending agency for the perform xwc of
use work for which this Pamir is issued (Sec. W. Civ. C.)
Landers Name
Lenders Address
1 certify that I have mad this application and sum that tic above information is
correct. I agree m comply with all City and caWly ordinances and SYm laws rtlating m
Wilding compunction, and hereby authorian representatives of this city to color upon the,
shove-menudgm Property for inspection purposes
1)
(We) agree m save, indemnify and kap hwsnless the City of Cupenino against
liecoisieibance enuecostaand expenseswhich may any way accrue against said City
orthegrantingofthisD
APLIC
NT
APPLICANT UNDERSTAN ND WILL COMPLY WITH ALL NON-POINT
WILL
SOURCE RE_ALATIONS.
Issued by: Date
Re-roofs
Signature al'Appliant,Conuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the'POcant or future Wading occupant shore w haMle lurallous material
as &f1had by 1M Cupertino Municipal Code. Chapter 9. 12, and the Health and Safety
ak. Section 255320)7
QYes ON.
All roofs shall be inspected prior to any roofing material being installed.
Will the applim, or future Wilding occupant uw equiprmnt or devim which
If a roof is installed without first obtaining an inspection, I agree to remove
mit hu'rsminm air ronu ninants as dcftmed by tate Bay Arca Air Quality Managemens
all new materials for inspection.
D strict?
QYes QNu
Ihavcucxdit uaMwx.m,rialam utt'��^�snot under Chapmr6.95ofdm Califm.
nu Health&SalnyCade Satiats 25Y55. 3kkW 2553d.luakrsusW thaifue Wilting
does not currently Is ant. Nat it' my rtffspoa ihility m motif y the occupant of tie
requiremcnu whicbj3fA Ersoes priors' a[. ream mf Occupmey.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner oramhmiiedaput Dam