080801110z
zC
W?
�z
UC
w
Cf
Fa
U2
CITY OF CUPERTINO
K
BUILDING DIVISION PERMIT
r
BUILDING ADDRESS:
PERMIT NO.
10620 S DE ANZA BLVD
TBD - TO BE DETERMINED
OPORnill
OWNER'S NAME:
PERMIT ZSUE DATE
:
CONTROL NO.
ARCHiTEC UENGiNEDI
BUITDINO PERMIT INFO
"
BLDG ELECT PLUMB MECH
LICENSED CONTRAC TOWS DECLARATION
Job Description
O
I hereby affirm that 1 am licensed under provisions of Chapter 9 (mmmendng
P
with Section 70W) of Division 3 of the Business and Professions Code, and my license Ls
in full force and effect.
T . I . REPLACE DRY CLEANING EQUIPMENT
D Clan�traanr
CLEANOUT-STRUCTURL
ARCHITECTS DECLARATION
I understand my plans shall be used u pubac tecot
Licensed Pmfessiontal
OWNER=BUILDER DECLARATION
I hereby affirm that 1 am tntempt from the Coni sewers license Isw for the
following reason. (Section 7031-5. Business and Professions Code: Any city or county
which requires a permit to conwuc4 aler. Improve, demolish, or repair any swcturc
prior to its issuarc0. also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's Licence Law (Chapter 9
Sq. Ft. Floor Area •
Valuation
(commencing with Section 70W of Division 3 of the Bushels and Pmfrssions Code) or
0
that be is exempt Iherefmm and the basis for the alleged exemption. Any violation or
4 0 0
APN Number
Occupancy Type
P y
Season 7MI.5 by any applicant for a permit subjects the applicant to a Civil Penalty of
not more than fidollars (SSW).
rive hundred doll
3 6 9 3 8 0 3 9 .01
C]L u owner or tM property, at my employe with wages as their role compensation,
Required Inspections
whit do the work sad the shuctwe is rot intended or offered Tor sale (Sec. 7W4, Business
and Professions coat= The cm,uactors Lints Law does not apply to an miner of
property who builds or improves thereon, and who does such wort himself or thmegh big
oven employees, provided tat such Improvements ate not Intended or offered for sale- If,
however. the building or improvement is sold within one year of completion, site owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.}
'M-4 u owner of the property, am exclusively coausoting with Ikeawd contractors to
convect the project (Sec. 7044. Business Lod Professions Code;) The Coouactnes Li-
masu Law don not apply to an owner of property who builds or improves thereon, snd .
who contracts for such projects with a contractor(s) licensed purstunl to the Contractor's
License Law.
❑ I un exempt Sec, B & P C for this muoo
tuunder
Owner /'�l/Q Date
��fY�x-
WO S COMPENSA77ON DECLARAMON
I hereby affirm wider penalty of perjury am of the following declarations
❑ I have and will maintain a Cardli rw of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insuruue, as required by Section
3700 of the Labs Coda for Use performance of the work for which this permit is issued
My Worker's Compensation insurance carrier and Policy number are:
Carrier: Policy No.:
cElir cA7E OF ExEmFriON FROM W OfmmT
COMPENSATION INSURANCE
(T his scaion need not be cmmpkted tf the permit is forone hundred dollars ($100)
.
or kit)
I certify that in the performanm of the work for which this permit is issued. 1 shall not
employ any person in sty mannc sy u �howms subjecdns,lhe Worker Cornpensadmn
Laws oCalifornia. Dla Y
-
AppBeant /1/f
NOTICE TO LJ ANT: If. dler making this cewricate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda you must
forthwith comply with such provisions or this permit shall be doomed re- mkcd.
CONSTRUCTION LENDING AGENCY
I hermby affirm that there is a construction lending agency for the performance of
the work for Which this permit is issued (Scc. 3097, Civ. C.)
LcnkesName
Lender's Address
I certify that I have read this application and state that the shove information is
'
coneeL 1 agree to comply with all city and county ordinances and sate laws muting to
building construction. and hereby authorize mprawnatives of this city to cola upon the
above-mendoracd property for inspection purpmses.
(We) agree to cave, indemnify and beep harmless the City of Cupertino splost
liabilities, judgments, costs and expenses which may In carry way acc= tpinu said City
9i4_0�
in consequence of of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date G� � —�
SOURCE RF>-i 770NS.
Re-roofs
L�
Si of ApplieanVConuactor Dale
HAZARDOUS MATERIALS DISCLOSURE
'Ihn of Roof
Will the applicant or future building occupant am or handle harardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safely
Code, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑y" /6Nn
a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or manse building occupant use equipment car devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Menagemau
all new materials for inspection.
D suict7
I have read to hazardous mncrials requimmcnu undo Chapter &95 of the Califor-
nia Heal th & Safety Code, Sections 25505. 25533 and 25534. I unde sc i d that If Liter building
does not currently have a leram, that It is my maponsibility to notify the omtnpant of to
requirements which mutt be met prior to tm,tincz: of a Certificate of Occuparey.
Signature of Applicant Date
All roof coverings to be Class "A:i' or better
Date
04'=' or authonzld ag t