02080098 OF
CI BUILD NG DIVISION
N0 PERMIT CONTRACTOR INFORMATION:
B�tIk6Dt3N�, MVENS CREEK BLVD DRAEGER CONSTRUCTION INC PERMIT02080098
KVAIN69: COMMUNITIES INC. #192 605 COMMERCIAL ST APPLICAnON$U�l1A"T�002
( PHONE'
(408) 536-0420 SANITARY NO.
l LCONTROL NO,
Mt 0 0 ARCHITECDENGINEER: a BUILDING PERMIT INFO
H y BLDG ELECT PLUMB MECH
LJ ILj t,
�N�
0Z z
LICENSED CONTRdunder$DECLARATION Job Description
OZt IM1ertbyaRrmNetlamlicensedunderpoulPromofChapter 9.d.,license ELECT SERVICE
ret-•u�i withS ait'](IOI11 of Div�.ion I the teas and Pmfcssinns Cole.and myli<ense
extm' is in fu me end cfiat.
K, 6 Licca lass '¢.at B
O e.�' Dale r- Co����rrariG���� 0
X 3 a�n --ARCHITECT'S DEG�AiII ION
Sto �indersmnd my plans shall be used m public records
taw a p O Licensed Proteuionul
OWNER-BUILDER DECLARATION
6n, 1 hereby affirm that 1 am exempt from the Contractor's License Law ror the
t-?< following reason.(Section 7031.5.Business and Professions Cade:Any city or county $210
etrn which requires a permit to construct,alter.improve,demolish,or rep it any shucture
a. chat
t t issuance,al requiresthapple t( hpxmtiuo file a signed statement - - - — — -- - -----
chath A luxassed pahifthomthepnnist. ff the ContractorsLicenseLow(Chepter9 , 316i2t101116or'®&ax : Valuation
(commercial,with Section 7000)of Divisilfthe business and Professions Code) St .is
or Our he is cxcmpi therehom and the basis for Ne allege)exemption.Any violation
-of Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty
of not m.m,han five hundred donar.S500). 304ARNNObUK ELECTRICAL''', : Occupancy Type
°L as owner of the propert,or myemployees with wages.:their side compecanoo, 501 — FINAL ELECTRICAL ENERGY
'-will do me'work.and the structure is not intended or offered for sale(Sec row; 505 — FINE �� ee[ions "
Business end Professions Code:The Contractor's Liana Law Joe,not apply to un
owner of pm,ny Who builds or improves Neeson,and who does such work himself
or through his own employees,provided that such improvements are not intended or F[����
`Rend for sale.If,however.the Wilding. 'm ment is sold within on e - f - --- -- E � - -
teompletion,Be owner-Wilder will have e burden of proving that he did not build or
improve for purpose of. 1.
_- . .. .. -AUG p q --
O1 ofthe propenY me clui IYcntmcin8 iN I' dontrvmorsto 2..-------- 02
El
construct the project(Sec ]006,Bui .ne d Professions Code)The Contractor s ` t
License Law does not apply to an owner of property who Wilds or improves thereon.
:. .-red who Wetowr,.for..,uch projetat,iN a commaor(s) licensed.purmant m.the. .__
Contraaorslicerml-aw. , BOILUI
°l am exempt under Sec, B&P C for this reamn
_ Owrii Date "
WORKER'S COMPENSATION DECLARATION
t
I hereby affirm under penalty of perjury one of the following declarations:
° 1 have and will maintain a Cenificme of Consent to self-insure for Worker's
Compemmlon, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is towel.
°I have and will maintain worker's Compensation Insurance.as required by Section
37W of the Labor Code,for the Performance of the work for which this permit is
i�M prker',Compcnsat W lnmmnce comer rind Policy number sm 4
rGa. �ul,Pul¢y No� � x 1� 1 P s .4 \ "j sA' t15 t)[Tk ;
CEI TIFl ATION OF EXEMPTIB OMWORKERS'�
COMPENSATIONIDTSURANCEr," " — _. -------- .__. . ..__ .._ .- ._
'(This section nee)not W atmpkicJ if N<permit is for rine hundred JLllars n t - 1
(b100)nr less.)
if y any person In tory meaner sec o to become subject
m the Workers .. .. ,.•� -• .•....-. - •� «._.-. .,,.- -
no cem l that in the Performance any manner
the work for which this tto t e Worker 1 .t
snag not employ :.t
Compensation Laws of California.Date
' .Applicant
NOTICE TO APPLICANT:If,after making this Cenificdte of Exemption,you should
Q 0 become subject to the Worker's Compensation provisions of the Lubar Code,you most
fonhw ith comply wird such provisions or this permit shall be deemed revoked.
fZ^" (iD CONSTRUCTION LENDING AGENCY
C ] 1 hereby infirm
Leahkf eh Oth.tt there is a cohswnlon lending agency for the perfommnce (//�/\/�//�/1���
hponart I,'.red Site.Built.Co.C)
0..Q Lc d Name . ._.. .. _. .. _.. .. . _ ...
a•Z
Leader,Addm. ' t .. .
V C) 1 ecifify that I tact,card this ppl' a ars!state Oat Be above i aforricafirmis ,
'A' correct.I agree tycomply with all city J n•on n:t and state la relating
. Ota to Wilding construction.and hereby authorize representatives of this city to enter upon
the alloc-rim boned property for inspection purpoa,,
(r y (N'qa rte m ime,i
'in
and&ep harmleu the City of Cupertino against
liabilities jn m is cost - J enpunas which may in any way acme against said
U Z City in ca qug,
n f ming of permit.
'^ AI'PLIG TI 'd DS ANDWILI. PLY 'TNA LNO'POL Issuedb Date
SOURC E T JIM y'
SignatureApr.talc tmetor: . .,e Re-roofs
HA ARDOUS MATCRIAI S DISCLOSURE
NII Nepplicotos future Wilding Lccupam shore or.handle harardom material Type Of Roof.
a.defined by the Curt Municipal Cod Chapter 9.12, J the Health and Safety , •
Code Section 255320 t ) :l `'B y ;. t p,`•4 „� .
°Yc`. ....All roofs shall be inspected prior-to any roofing material being installed. .
will the appr,am orfummmaddingL,.pant use equipmem mdevice,which If a roof is installed without first obtaining an ifispection, I agree to remove
sort haactrdous air contaminants as deli ythc Bay Arta Air Quality Management
Dinda tl � all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.,
I have read the hazmdpus materials requirements under Chapter 695 of Ne
Cal111.1.Heat Safpty C, e,Sections 25505,25573 and 25534 1 understand that
if Ne building o ytu By have moral.that it is my responsibility eco notify the
acupant tfI e W s which most he me prior .issuance of a Cenifcme of
a,ppatcy Date. _
n _ Signature of Applicant
mmag t All roof coverings to be Class "B" or better
�, OFFICE