03090061 CITY OF CUPERTINO
BUILDING DIVISION PERMIT SCO VTR"GTOR INFORMATION
BUILDING ADDRESS: YMP INC PERMITNO03 O 90061
I Q26;5 RRRT AVT?,
` NI:R'S NAME: 21009 SEVEN SPRINGS PWY PERMIT ISSUE DATE
TEH E & H 3RD 2003
PONE: (408) 996-2670 SANITARY NO. CONTROL NO,
ARCHITLCT/ENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+00 LICENSED CONTRACTOR'S DECLARATION
ATION
1 hereby affirm that 1 an licensed under and
Professions
ors Code. 9 my license is Job Descri�l� ^ p
£¢� with Section 7010) DivisipnJef me Busing inti Pmfcssinns Codc.and mylicenu is ��U111 �G®
'n. inrmlmmey,N erred. Svs ADD 2086 SQ. FT. 0��1111111�6
LieenmGlaS' �... JUN
t,ou
Data Contacro, 2zk 2004
ARCIIITECTSARATION
I as J -I, I endcrsmnd my plans shall W used as public¢conk
>aU
s S Licensed Promen. 1 BUILDING
AIL®'ss
,p�pl.G
�p 0 NER BUILDER DECLARATION
A a y I hcrcby affirm that I am exempt from the Contractor's License Low for the
0 0 following reason,(Section 7031.5,Business and Pmfceions Code:Any city or county
<mwhich"mars a permit a constmet,alter,improve,demolish.m mpan any s ntu tum O O O 0
J2>
poor to in issuance.al,mon,ires theapphcant rorsueh permitefile asignedwaincin
_s<
that heislicensed pursuant othe provisions ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
is 1-0 (commencing with Section 7QXR of Division 3 of the Business and Professions Code)or
$ mal W is exempt dominant and the hesis for the alleged exemption.Any violation of 37510016 . 00
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of ane APN Number Occupancy Type
not mom man five M1ondrod dollars($500). P Y YP
❑I,ns owner of the pmpeny,or my employees with wages as their sole compensation,
will do the work,and lie abu gum is not intended or offaed for sale(Sec.7344,Business
and Pmf ersmns Code:The Conmclors License Law dna not apply to an owner or Required Inspections
property who build.or improves thereon,ane who dmssmh work hfmwif or thmugh his
own employes,provided Boatman impronmcnm mind inlcMeA oroRemd for sale.If,
however,the building or improomical is sold within one year ofcompletion.the owner
-
builder will have she burden of proving that he did not Wild or improve for purpose of
aa1c.).
O 1.as owner of the property,am exclusively contracting with licensed convectors to
construct the pmject(Sec.70,14,Business and Professions Code:)The Contractor's Li
cense Law dues not apply to an owner of property who Wilds or improv¢tham.n,and
who commits for such projects with a commit.,O licensed pursuant to Be Contnacs'.
Lice .Law.
p 1 an exempt under Sec. .B&PC for this mason
— r Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of Perjury one of the following declarations:
❑1 have and will maintain a Cen ficom of Consent to scl6imum fur Workcr'sCompcn-
Workfor
, provided for by Scction 37W of me Labor Cnde,fm the performance.f the
work which this permit is issued.
O 1 ban and will maintain Worker's Compensation Insurance,as required by Section
3708 of the labor Codc,for the pertorm circ of the work for which this Permit is issued
My Worker's Compensation Insurance carrier and Policy number am:
Are > L Policy No, 12 3 7 T
' CERTIFICATE OF EXEMPT! OM WORKERS'
COMPENSATION IIJSU RANCE
('Ibis section need not W completed if the permit is for one hundmd dollars($100)
m less.)
I cenify Nal in the performance of the work for which this permit is issued.I shall not
employ any person in any manner an or to Wcome subject to tax WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenifieam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Codc,you must
J z forthwith comply with such provisions or this Permit shall be deemed revoked.
ti Q CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there is a conauuction lending agency for the performance of
But week fur which this Fired,is issued(Sec.397.Civ.C.)
:n,I Lender's Name
Lender's Addscss
7 z
J O 1 cannily Nat 1 have read this appfictokm and sem Oat he above m orindom is
i F torten.1 agree to comply with all city and county ordinances and stain Dwi elating to
OV
building construction,and hereby atobonprTemnmivesof Niscity toerrorupon the
ahconsequenceeo the gran for inspection purposes.
F y (We)agree to save,indemnify and keep harmless the City Of Cupertino against
fn limildies,judgments.costs and expenses which may in any way memo against said City
Uz APPLI ANT UNDERSTANDS
of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC REGULATIONS.
%<�> 11S'D3 Re-roofs
Signature of ApplicaContractor
H HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will me ippRe nlor fmitre building meupantsmr,.,handle h.,.deus material ,
as defined by the Cupenin.Municipal Codc,Chapter 9.12,and the Health and Safety
odc,Selo n 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
Ycs
wee the annfieam or mw c Gilding occupant If a roof is installed without first obtaining an inspection, I agree to remove
pan equipment or devices which g P
cmlt hvardous air coots./ Gncd by Be Bay Area Air Quality Management all new materials for inspection.
District,
Oyes
1 havemad Nc haimshms mate'als requirements under Chapter 6,95 of me Calder-
niaHealN&Safc,yCWc,Smdons2550515533and25534.lUndCM fid Naif Ne Wilding
does not currently have a tenon,mat it is my resrymsibi lily t.non fy the rocupant of Ne
mquircme vwhiehmustWmmptiertuismeomoraCenircam. eGpan . Signature oCApplicant Date
jl
O;t,or inumnixed.,car I Date All roof coverings to be Class "B"or better