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07110150 CITY OF CUPERTINOBUILDING DIVISION PERMIT4C(SNCFRAGT,QRIIVORMATIgN - Buaq�l-RT'8E9s$TEVENS CREEK BLVD TBD — TO BE DETERMINED P07110150 HER'S NAME: FW(.MJT ISSUE DATE BYER PROPERTIES RITZ #562 02/06/2008 HONE: SANITARY NO. CONTROL NO. ARCHRECTIENGINEER: BUILDING PERMIT INFO BLDG � 0 PUMB MECH IS 0 30z LICENSED CONTRACTOR'S DECLARATION Job Description rd u 1 earthy affirm Nal 1 Am licensed under provisiau of Chapter 9(eommeuing P with Section 7")of Divhkn 3 of the Business and Profusions Code.and my license is COML TI, BUS SPAC NON—STRUCTURAL Is Nn forte and S S.l C I S . 5�z ucenmc t.e.« Dae L Comrumr p 1 1 4. yt{ ARCHITECTS DECLARATION -1 A SSO fG I undersand my plans shall No used u public records ] bX Licensed Professional - pOW NER-BUILDER DECLARATION S mA E 1 bertby odtam that I am exempt from the Caneacme3 License Law far the DO following mason.(Section 703 1.5,Basin=and Rofeasiom Code:Any city or county 12 which requires a permit to construct,mer.Mprow,demolish,or repair any sanctum -iy prior to its issuance,Alan requires the applicant for such permit N file a signed sutemem Nal he is licensed pursuant to the provisions of ten Corbuwfs lJceae Law(Chaper9 Sq.Ft. Floor Area Valuation (commencing with Section 7000)of Division 3 of the Business And Pmfuamns Code)or $80000 e3 9 Nu be is aampt Unn efrmo and the basis fm that alleLed exemption Any violation of Section 7031.5 by airy applicant fm a pemdl subjeeu the applicant An•civil penalty of �t,�tumber Occupancy e not roam Nan A.hundred dollars($300). .3 5 9 0 8 0181"G' P y TYP ❑I,ummofthepmpeny,wmymploy=WiLh mutheesulecompenudon, will da the wont,and thesauurum k nminem W ar.Rertd forsak and Profession Cade:The Comcmts Liam Law dee rot Appy An an owner of - Required Inspections property wind bui Ida ar improws tbemon.And who does such weak himself ar through his own employees,provided that such improvements are not intended araQertd fmsae.If, however,the building or Impmwmeni is said within am yea of completion,Are owner. buildm w111 haw the burden of proving that he did rot Mid or improw for puryoAe of ask.). ❑1,As owrwr of the property.Am amusiwly conuuring with Iiceued cemmumem in camwcl de project(Sec.7044.Baine And Pmfesiam Cade:)The Convenes Li- cede,law does not apply At an owner of property who builds or Imptem demon,sed, who contracts rot such pmjecm with a doneutar(U licensed pursuant w the Contractor's License Law. ❑lam aempt untie See .BAPCNr Wsmuon Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the fallowing declaradartc ❑I ham and will maintain•CertiOcam of Consent to self-iuumforWorahCamper. mean,u pmvided for by Samoan 3700 of the Labor Cade.for the Performance of use work for which this permit k issued ❑I Mw And will maintain Warkses Compensation Imuura,As required by Section 3100 often tabor Code.for the performance of the work formich this permit is lama. ' My Worker's Compcnytion Insures carne ad Policy number are: CArtier.� ,6t4 O Mcr6Al P.IIc N.A/C >_— It lil 3 37 40 CERTIFICATEOF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This station need not he completed If tbe Permit is format hunthed dollars($I00) nr less) 1 anify Not In the performance of the work for which this Permit Is Wood.I shall not . employ any person in any mmmrw as e becoma subject to the Workcn'Compenuom Laws of Cahromia,Dam Applicant - - NOTICE TO APPLICANT:IC AMr making this Certificate of Exemption,you should become subject w the Workeh Compensation pmvlsiom of Ne Labor Code,you roue .J O fmNm Nm with comply with such provisions is permit shall be deeed avakcd. Z" CONSTRUCTION LENDING AGENCY (-nom 1hereby affvm that Nem is a construction lending agency for the performance of Cthe work for which this permit is issued(Sec 3097,Civ,C.) 4 Q Lender's Name 7 Z Lenders Address U O I certify that I law read this application And sue that the above information U II.E seal I agree te comply with all city And coldly omlnuxea and sae IAM misting in .O building construction.And bertby suthonse representatives of Nis city to enter open the 12.1 above-mentioned property for inspection puryasea (We)agree to sew,indemnify and keep barmleu tit City of Cupertino Against cn liabilities.judgments.cuts no expeuu which may In any way acme again said City U Z In couequenco of the granting of Nis permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SQ�IRCE ROGUI�170N - 1 N 2 /CXRe-roofs BILa0luR of ApplieRDOW HAZARDOUS �. HAZARDODO US MATE RIALS DISCLOSURE Type of Roof !/ Willy t e Cupertino u Nluni building eamput Awrt Atlantic the h eallou malarial As de0ne0 by the Cupertino Municipal Code.Leper 9.12 and Ne HwIN And Safety Section Z5324)? ©,Ha Or, Will roofs shall be inspected prior to any roofing material being installed. ❑Yu Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove emit Mlsn nu air contaminants As defined by the Bay Ara Air Quality Matagement all new materials for inspection. District' ❑Yes �u I haw mad the ha»Nom m.H.Is mquirtmenta underChaper 6.95 of the Gmifar ria Health @ SaeyCode,SAm.5505,25533 and 25534.1 undersand Itis if the building docs not cuonn ly haw a tonna that itis my mspontlMlity to ratify the occupant or Nc mgmm1�tawwmts, Aunptlormiss,aacofaccrt(reaucaranp . Signature of Applicant Date / /C ado All roof coverings to be Class"B"or better Owner or AUNomsd gent Dam' ' g