03110082 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUIIAINGADDRESS: """ 03110082
2nsrtz VAITRY rpppy n]R
OWNER'S NAME: PERMIT ISSUE DATE
I �ETRO
SANITARY NO. CiiOl,NO.
BUILDING PERMIT INFO
ARCHTTECTIENGINEER: BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION Job Descrip
mtion
I bereby iffroan that I wou licensed under provision of Chapter 9(commencing
-iacto.7(XK1).fD1vi,m.3.f the Basin.and prodlessimes Code..red my license I,
in fall fares and . C_ 0 --CELL SITE
Zest oso class Lie. TI
—6 Contractor
ARCHITECTS DECL'i CONTRACTOR: PARK PLACE CONSTRUCTORS (02/18/04)
A M�
TION
I understand my plans shall W used as public records;
Dy
Licensed PmfO,,i...I OWNER-BUILDER DECLARATION
I hereby affiren met I am exempt from the Connommes License Law for the
following remosen.(Section 7031.5,Business and Profession Code:Any city or county
?�tZ� which require..permit 1.construct,.1mc mineve,demolish.or repair any structure
lypri m its issuance.also re,ums the applicant for such permit to rile 4 signed summern
that M is licensed pursuant to the provisions of the Contractor's License Law pCh.,mr 9 Sq.Ft.Floor Area Valu$t0000
(commencing wid0inction 7000)of Division(
of me Business and Profession&Code)or
that he Is ausemp,therefrom and fam bessix;for flas alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant 10 3 civil penalty Of APN Number Occupancy Type
not more tuart five hundred dollars($500).
0 l,mowwofthepmKnymmymployenwiffimgumLheirsokc=Mnndon, 32610044 . 00
will do the wealk,and duharachum is mninterendad oroffiered formic(Sec.7044.Business
and professions Code:The Comonabor's License Law dao no(apply to art owner of Required Inspections
propanywho buildtorimproves Herron.and who does such work himself orthrough his
own employees,provided donsuch improvernema has not intended arafferadi for sale.If.
however,Ine building or improvement is cold within an year of completion,the owner.
builder will have the Women of proving that he did not Wild or Improve for purpose of
❑1,as moser of the property,am exclusively contracting with licensed conermums to
construct ft p.jca(Sec.70",Business and Prefroadons Cattle:)The Contractor's Li.
comes Law coca not apply On an Owner of Property who Wilds or improves themon,and PIN
who contracts for such projects with a commator(s)licensed pursuant m the Contractors F
License Law.
El .exempt under Sec. ..B&PCIforthis orman,
Owner Dam "?004
• WORKER'S COMPENSATION DECLARATION
I hereby arm under Penalty of Perjury one of the following declarations:
0l have and will maintain a Condiment of Consent W scif-firmum for Worker's Compen.
sation.am provided for by Section 3700 of don Labor Code,for the performance Of the
work for which this permit is issued.
0 1 haw and will maintain Worker's Compensation Insurance,wt required by Section
3700 of Its,Labor Code,for the performance of the woul,for which this permit is issued.
My Wookees Compensation Insurance caniff and Policy number am:
Carrier. Policy No.:7'1-91
CERTIFICA OFFMPTION FROM WORKER)fV 0
COMPENSATION INSURANCE
Mis;eeolunrecd act On completed Iffloc Permit is forma,hundred do[].($1(10)
or less.)
I cenify that in the pcsformance,of the work for which this permit is issued.I shall nut
employ any person in any matter so as ut become subject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT'.It after making this Ccotifleato of Exemption,you should
Income subject W the Worker's Compensation previsions of the Labor Cocar you most
Z forthwith comply with such provisions or this Permit shall he doemed revoked.
z 0
CONSTRUCTION LENDING AGENCY
1 incrub,Orion than there il.c.astrumban leading a,.,to,me Perfurmaneciff
ai> due work for which this;permit I.issued(Sac.3097,Civ.C.)
Uj
04 Lender's Nuanc
Lcmia,'.Address
U 0 I certify that I have mad this application and stake that the above infummobart is
I,, correct.I agree to comply with all city and county ordinances and state laws rchating to
0 SV^ building construction,and hereby audurim representatives;of Nis city to enter upon the
above-nerditmcd property for inspection purpacca,
(We)agree to save,indemnify and keep hurpless,the City of Caperton againal
U in consequence or line granting of this Permit.
c,) liabilities,judgments,costs and eaqcmin which may in any way seems,against mid City
APPLICANT UNDERSTANDS AND WILL COMPLY WH ALL by i ALL NON-POINT DateZ o 5/
Re-roofs
SlInature of Aprlicxu =,n, Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicator or future building occupamston,or handle meadows material
as defined by the Cuponfirm Municipal Code.Chapter 9.12,and flue Health bad Safety
Code.Section 25532(.)7All roofs shall be inspected prior to any roofing material being installed.
0y. ZNO_ ._
Will tacapplicant o,future an Id If a roof is installed without first obtaining an inspection,I agree to remove
emit cupaun use Torment or dc,mes;which
hanodous air cormanonso the Bay Amu Air Onalky Management all new materials for inspection.
District'
0 yes C]No
I have read the harardous materials requirements under Chapter 6.95 of the Califor,
ma,Hurin&SurtyCoam,Sadao 25505.25533 and 25534.1 understood that ifft building
does Out currently have a meant,met it is;my responsibility to notify the mcupwal of the
equi 0W anc""umm.of a ccrurcam of Occapacy. Signature of Applicant Date
r-7 —I X�� All roof coverings to be Class"B"or better
1Ownuhjrr'authorind agent Dam