04120056CITYOFCUPERTINO ":.... -..... _.
BUILDING DIVISION'. .PERTV�i1'�V-
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BUIL DING ADDRESS:
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PERMRNO
04120056'
10201 TORRE AVE
ER's NAME:
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PERMIT ISS IE DATE
PORTAL '
ONE:
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SANrrARYNO. CONTROLNO. -
ARCHITECTIENGINEER:'
BUILDING PERMIT INFO
BLDG ELECT PLUMB - MEC"
0 0
98
LICENSED C'ONMCIDRI DECLARATION
Job Description • - -
if
I hmeby afRfm ddo,1 sm lumand'under provisions of CNpun 9 (commencing
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MWSaUi]IXO)hl DlHtlhn lar NC Budreasand Profeaarna Chde.aM myliunse4
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30 -DAY TEMP PERMITLhua
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EXPIRE ON 01/08/05
wm Contractor
ARCHITECTS DECLARATION
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1 unm arond my phos Mall W used As public records
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Learned Professional
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OWNER -BUILDER DECLARATION
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I thereby in. that I am exempt form Ile Citrunofa LiCanse Law for the
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following moon. (Section 7031.5, Business and Proftadom Code: Any city or county
which mquiru a permit to canancert. tlec improw, demnliM, or repair any structure
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prior m its issuencc.atsu MPrmM the applicant foraih posit m 01C• aioncd wemcnl
Nlhecnatmcmesumceuw(eh.m.9
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Ft. Floor Area Valuation
Sq.. $0
FF c
mdpul.uan"othapmHaana
wthe BRnm
3 Buxmorsmd Profrulon Codc) or
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d $
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(Commencing with Section ]B00)off Division ofde
Wet he Is exempt demfrom and the basis for the alleged examines. My violation of
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APN Number
- Occupancy Type ---
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Section 7031.5 by any applicant for. permit subjects We applicant m a civil penalty of
net mom Wan five hundred doll= ($500).
'. 36901020.00
❑ L u ownm of dm pmpMy. w my amployeta withwtu u thebmmcompewdan.
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'- Required Inspections
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willdh thewod.aM We almctum hnutintendeA araRered funk (Sec. 71W. Burreu
and Prolesdom Cade: The CommtorY L+mnae Law data ant apply m an ostler or
property who builds or improves Umreon, and who drcuwh wort himself. through his,
own employee. provided Chat such Improvements am not nteded orhaemd foraale. If.
Temonra rv
however. We building at Improvement is sold within ane year ofcompledan. the owner.
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ball will hive We burden of proving bun m did not build or Improve for purpose of
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Issued prior to plan check completion
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:I. u Cwna of the propenY• am ucluslvely contracting with licensed conuactom to-
a timet the pmjeci(sec.70". Business and Profeation Code:) The Communes Li.Contractor
.and/or Owner accept complete
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come Ica docs not apply to an owner of property who Wilda or improve Wemon, and,
who Conlncufar such pmKcus wild a cantracmr(q licensed punwntm the Contracmra
.r- ._responsibility for correcting additionsg
Limnse Law. ..
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❑ 1Amexempt25 .BkpCforWbmuon.
Da
r RK +ATION DECLATse _
- _ „ - omissions and -revisions on
-.. compieterd Toe Prints.
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i d shembyafnmmderpmatjofpeduryahfthfa
Permit jgc� t30
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Compact-
I have and pmvldc far the performance
provided for by Section 3100 of tie IaWr Code, for the perfhnnence of the
mirk, ardo. 370 of do, Labor
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From'
wad far which this Permit is issued, _ ..._ .
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❑ I haw and will maintain Worker's Compensation Moue me, as required by Schon
37m of the Labor Code, for the performance of the work for which this permit is Wood.
Polity
gnaa rc:
My Whrket'a ChmpenaMon lnwreit Cartier and numberam:
Carrier. polity No.:
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CERTIFICATE OF EXEMPTION FROM WORKERS
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COMPENSATION INSURANCE
5
(1113Auction Med not W completed if the lennh is far One hundred dollars(51m)
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lir less)
1 mNfy that in We pedarmance of the .,it for which this Penult is issad, I mail Can
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employ anypef30n in my monarch as m became subject retie WadeWCOmpemaJOn
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LA. ofclir.mi. Dora
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Applicant
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NOTICE' O APPLICANT: If. after makino this Ceni0cae of Exemption, you Mould
become subject to the Wader's Compensation Pro tans of the labor Code. you mum
foMwirh complyu "it with such provisorit Permit Mall In dared mvrked.
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CONSRIUCfION LENDING AGENCY
1 bemby arfm Wel them is a ConMmction lendingagency for the performance of
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Ilse wurk far which this acmes, is issued (SIL. 3(Y9]. Civ. C.)
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Lemice: Address
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I certify that I haw mud thirty and coup and stale Wm the eWw information rmNm Is
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coedit I corm m comply with all city and county ordinances liMOf and sole law open
hereby al this city Tenor upon Ue
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forimactiorirzmpresenul+w
ahow-{cutionadon.and
ahOve-(W)3& C,anY forinanify Anpuryuea
(s Ju agora m cost, indemnify and trey harmless tie City or,against Against
Cty
eapmtsuwhich mryin my way acme against acid City
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incronsequadeofthecoatsand
APPLIICCANf UNDERSTANDS this permit,
WILL COMPLY WITH ALL NON -POINT
Issued by: Date sAoo
SOU U ONS.
Re -roofs
qct rApprcm r
H ARDOUSMATERIALS OISCLOSUR
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Type of Roof
WIII de applicant or future building icup at num or handle huallous material
de0ned by the -C mo Municipal Code. Chapter 9. 12. and the Health and Safety
e, $.'Non 25331(.')7 `,
❑ym ®No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or (future building occupant use equipment or devlms which
huardhu dr mnuminenu as dcMCJ by de Bey Arca AieQuality Management
all new materials for inspection.
`��ElYu�}Uu
7M.triet?
I haworad the haamouimamrialsmquimm munderChaper6.95oftheCelifor.
icelth&SMetyCode.Scedi.253115,25377and27534,1undrsludWetilthe WiIJinS
a mel cuhenlly haw a mount, door I y ma ihillly a idly tie ar.m.1 Of the
ireme tswit el ph As haccrincamofOcmpncy
Signature of Applicant Date
All roof coverings to be Class "B" or better