08090112 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CO : T CTORI ORMA.TI Nis
PERMIT NO.
Bml.l'trjcppgtlEs DE ANZA BLVD STE 210 TBD — TO BE DETERMINED 08090112
VNER'S NA PERMIT PERMIT ISSUE DATE
DE ANZA MEDICAL LLC 10/07/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
up p LICENSED CONTRACTOR'S DECLARATION lob Descrl tion
4 mF 1 hfirm W
ereby afal l am licensed under Plovidom p
of Clun,9(...'a$ P
wiWseetion7").fDirino3ordmBusinessandPmfesdnmCodc.andmyIke=Is T. I—MINOR REMDL(E)DENTAL OFFC,REMOVE NON—BARNG
^ F in fall forte and efrett
: z Luame Clues Lk.is WALLS, RELOCATION OF PLMBG, ELECT.NO NEW
nFp DataGuidacler
e 7th ARCHITECTS DECLARATION ELECT/PLMB
e 1 undersand my pew shall be wed u public rands
ADDED.NO CHANGE TO(E) SPRINKLERS(455SQ)
a G G Licensed Professional
3 OWNER-BUILDER DECLARATION
I hereby affirm Wel 1 am exempt from the Conuacloes License Law for the
no following moon.(Section
7031.5,Business and Profrsdem Codc:Any city or county
which ter,does a Permit to conurv0.aIle.earn.,demolish,or repair any suuclum
–z i- Prior to its uswnce,also rcquidea thetriplicate for such permit to file a signed atamment
y+�
EE ng thatOu'reedruionestalheprviamnlOftheConuacto-Uccuselsw(Chapm $40000 r9 Sq.Ft. Floor Area Valuation
(commenringwiWScrion70W)o(Dtvuion3Oftis Businmand Profs amCadc)w
ay Wal heu exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by my applicant far a permit subjects the applicant to.civil penalty ofNumber Occas
ml mart Wan two hundred dollus(SIM 36940039 . Occupancy Type
❑1.u mmcr of Us popery.a mY evPloym wen cages u Ihc'v sou mmpewtion,
will de,the work.add the struerme is not kunded or offered for sale IS..7044,Business
and Pmressiom Code:The ConlMor's License Law does an,apply to an owner of Required Inspections
propeny who builds orimpows Unmon,and whodoessuch work himselfor though his
ownemployces.Prowided that such improwemmU am not trended aroRucA forsale.lf.
howcser.We building or impne mmen u sold wituin one year of completion,the owner-
builder win have tO bullets of poring that he did fat build or lepers for puryas of
sale.).
71,1:u Owner of the pmpenY,am eulusively contracting wide licensed mnuactan W
construct than project(Sec.7144.Business and Processions Code:)The Contractors Li-
cause Law does not apply in in Owner of property who bui4s or imp owns themen,and,
who ern u cu for seen projects with a eonu acurds)licensed pursuant to We Conuaators
Isans Law.
❑leer saamp un �) .B B P C for this reason
i�u0 1/ii.. Data
WORKER'S COM ENSATION DECLARATION
1 hereby aff re under Penalty of perjury own of the fallowing dauntiont
❑!hire and wBI maintain a CutiOam ofConsnt to elf-iuvrt fa Workers Compeer
nation,u provided far by Section 37110 of the Inbar Cade,for one performance of the
work for which this Permit is issued.
1 have and will maintain Workers Cnmpemadan Insurance,u metered by section
3700 of the Labe Cade.for the perf.rmmec.f the wwk for which dus Permit is issued.
My Worker's CompenWion Wean¢artier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(Thu seedmr aced mtheconpleted Waste permit u foram hundred dollars(SIM)
uslas)
I cedh than in the peformanee of We wort fwy�beth Nis permit u issued.l shall ml
employ any'dam in any ai=r)'Larof�sgy4Et so the workers'Compensation
Laws of Califond / 7u[
Apple '
NOTICE TO APPLICANT:If,a r making this Certificate of Eumption.you should
become subject in the Workcrs Compensation provisions of ten Later Code,you most
.J z forthwith comply with such provident,or this Permit shall be dccmed marked.
Z 7) CONSTRUCTION LENDING AGENCY
l hereby afam Wal there u a counteraction lending agency for the Performance or
r'5: We wort for whim this permit Is issued(See.3097.Civ.C.)
IT]s'7 Lenders Name
Dz lenders Address
U Q 1 cenify that I haw rend this application shad sum that the abow Waterman is
W coma I agree to comply with all it,and county odI.a and sou laws relating he
Wilding construction,and hereby authorise mpmlenudva of this city he encs upon the
r IS7 abawe-motioned property far inspection purposes
pry (We)agree to...indemnify and kap harmless the City Of Cupenim gsine,
liabilities,JWgmenu,cod and expenses which may Warty way amus ageimt said Cly `
U 7 in Consquenee of the granting of this permit
m� APPLICANT UNDERSTANDS AN WIL OMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCEREGUI�T ONS.
`Yrs %moo Re-roofs C, t
Siyuone of Appliam/Conuaner Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding occupant amm.,handle hi ureaus material
defined by the Cupertino Municipal Conic.Chapter 9,12.and de,Health and Safely
41 dc.Seethes 255324)? All roofs shall be inspected prior to any roofing material being installed.
Ya
Will the.ppficanl or[.tore Wilding occupant ter N.ipmenl w de`•oats which If a roof is installed without first obtaining an inspection,I agree to remove
emit hasardaus air conumimnu in dcfined by the Ray Arta Air Quality Management all new materials for inspection.
District?
❑Yea awO—
I haw mad the hasadem coneodsoupdre enuundercupc06.95.fIOCatifor-
niaHas &SafoyCode,Swd=25505,25533w25534.IwWcnuMWuilds builWng
does ms'curmndy has a tenant del it uy mapomibility to notify the Occupant of We
mquimmcnmw hmuu Oma
szorbit ante Oh CenlfmamorOcapncy' Signature of Applicant Date
moo
All roof coverings to be Class's"or better
Owner m authorised agenl Dau"
C