04010144 CI'T'Y OF CUPEKI'INO �i�"g:. nr3 1���]�^��_ �p
BUILDING DIVISION PERMIT WONTRACTOR�INFORMATIO
A4WU a
BUILDINGADDRESS: "" DPR CONSTRUCTION INC PERMITNo04010144
NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO, CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o o LICENSED CONTRACTOR'S DECLARATION Job Description
V❑❑ I hemby a11mor Nal I am licensed under previsions of Chapter 9(commencing p
z1W withgeetion )of Division 5.(the Bud nd Profession C.&.and my license is
^ u in full force o ffec �I
y�z uxenacl O L ?/9,`/33 REPLACE PARKING LOT LIGHTING BC-'RL
Contruer Lrr4d A I
Oq ARCNITECTQLARATION
�cU Iuru nd my n u
rpublic records
hG�a LicenuJ c 1 �5/
y OWNER-BUILDER DECLARATION
0 0 1 hereby maso affirm that I em exempt from the Cssimrs o License taw for ny
p O followwhich
mason.sccoarch t ]kDLL Business and ve,de o demolish.
Code:Any tiny nr county
$ which rcyulres a permit re eonstmCL•@a imprero,dcmnpitt or repair ed mmeent
prior its ieued Pursuant to
applicant Of(he suchpermitmcele s Law(Cha meal
g (that Coma incingsedPursuanitotheofDiviaunroftheBuwmrinicenselaw(Choder9 Sq.Ft. Floor Area Valuation
s�~$ (cam Zia exempt
Section 7030)of Oivisiofroflhe BminwuWon.An li Qge)or
Net io u ea1.5 b therefrom and the aper(or be alleged cxcmpnit to Any l Pers fry of
Section IDy13 Live
any red dot for a permit subjects Ne applicant m a civil penehy of 3^A,pwrrNs. to O 0
not more Nan Bve hundred dolrn(5500). Y"O'U7J VW'DD OO'' r � Occupancy Type
❑I,uowner a(the pmpeny,umy employcu with wages dreiiaNC ombpnallonf —_
.[lid.We work..nd dondooure Isrohunbcdorortered It,et e(Sea.]014.Butriesi I i — __
and Prefeuions Code:The em racer.License Law taw does apply to anLawner of t I �s r" j :—-.Required Inspections
Property who buildsor lmprews thereon,and who doesauch worIch"Iforthrougp his -
owncmployetis,provided N2=110pnwmenu art no un tsrdRered(COL If.
however.the buildingteb r improvement is at he did
oae w f tom too I. p�ner-
builder will hero the burden of proving Net he did not null : Ire ow f a,Fick\`\�tof 1U{
sale.).
❑I,pe owner of the property,am exclusively contracting with licensed cone MOM o -
Cdpemdxt the project(See.7W4,Buimeat and Pre feasiope Cade:)The Contracted Li.
cense law docs not apply to an owner or Pmpeny who builds or improves Merton.and
who Contracts for such projects with a contractor(a)licensed pursuant to she ConV.Ctors
License Law.
❑l un eaempl under Ste. ,B k P C far dos reason
Cr
Date-
WORKER'S
abWORKERS COMPENSATION DECLARATION
I hereby afrum under penally of perjury one of the following declantiou:
❑1 have and will maintain a Cenifiate of Cmuam to self-imum for WorkeACompen-
serum,as provided for by Section 7700 of be labor Cade,for Ne perfannunce of Ihe
work for which this Permit is issued.
I have and will=n.Iatn Wmkefs CompenaIIoIt Iuunna,a nqu1red by Section
] a(Ne laaor Code.(or Ne perormatt of the work for which Nis Permit is ipeud.
rkef Compensation Insurance amu ad liry number art:
men PION No,:�A P46
CE FIC COMPENSATION
ATION ON FROM WOR ERS
COMPENSATION INSURANCE
(Thr sextan reed norhecompletetl if Ne Permit is roronchummocl ciallan(SIM) .
or less)
I certify Nu in the performance of the work for which this Permit r issued.I shall not
employ any person in any murer w as in become maker to the Workers'Compensation
L.waof California.Data
Applicant
NOTICE TO APPLICANT:If,after making Nr Cci ificam of Exemption,you should
become subject to the Worker's Compeos.lion provisions or the labor Code,you mum
wJ O forthwith comply with such potions Or this Permit Mmvok
all he dcacd reed.
CONSfRUCnON LENDING AGENCY
[—� I hemby affirm Nat these is a Construction Lending agency for the performance of
fY' NC work fur which Nis psmit u laced(Stt.Jo91,Civ.C.I
gi7 Lenders Name
'
D Z Lender's Address
U Q 1 certify that I haw rod this application and cote that the above information is
14 E" CORCCL I agree to comply with all city and county aNiunces and stale laws relating to
O[, building construction.and herebyauNorire opstrantuivcs of Nr city a corer upon toZ / /
W show-mentioned pnprny for inspection purposes.
[y, gL (We)agree to pew,recertify ped kap harmless Oe City of Cupertino against
s iA liabilidaa.judgmero.costs ped expenses which may in any way accrue against said City
(„) 7 in consequence of the gaming of thu permh.
rte• APPLICANT UNDERSTANDS AND W L COMPLY W_ ALL NON-POINT Issued by: Date
OURCE RE LAT( S.
4gW_ -� Re-roofs
gn ( Ir HAZARDOUS MATERIALS DISCLOSURE Date Type of Roof
Will Ne applicant Or future building occupant Bort or handle hazardous material
u defined by the Cupertino Municipal Codc,Chapter 9.12.and the Health and Safety
.SccOnnsssszar
❑Yns emsinspected All roofs shall be prior to any roofing material being installed.
Will he applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh hanrdnu te
DisuictT r cenuminanu u den by the BayArca Air Quality Managementall new materials for inspection.
❑Yes
I haw mad rite huaAtusmaterer requirements under Chapter6.95 ar NC Cahroo
ON F1caIN A Saety Cada,Sttuoru 25505.35577 and25534.I understand thmif thou building
Jou Trot currently haw a tena4 Net it u my res nsi1i1itY tu rmdl'y the occupant of Nu
mquiemxnuwhichmumhemntprortsi dance sOcrureacorocapugy. Signature of Applicant Date
r •
Due All roof coverings to be Class"B" or better
Owns a egcn