05040043CI TY OF CUPERTINO�<
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BUILDING DIVISION PERMIT
CONTRACTOR*INFORMATIQN, Vin.
BUILDING ADDRESS:
460 RUR Pn
BERG & BERG
PERMIT "'0.05040043
OWNER'S NAME:
PERMIT ISSUE DATE
BERG &
E:
SANITARY NO. CONTROL N0.
ARCHITECrENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 herby affirm that I am licensed under provisions of Chapter 9 (commencing
with Second 7NXo of Division 3 of the Business old Profcssiam Cock, end my licens u
m hedeoma anaeff"`
TI --INTER. (NEW OFFICE/WALLS &
License Class Lie.
Doncomrawr
SHOWER/HVAC)
ARCHITECTS DECLARATION
1 understand my plans shall W used ns public remands
A
J
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from Ne Contractors License Law for the
following reason. (Second AT I.S. Business and Profcuiom Cade: Any city at county
which requires a permit id cnnVNct, alter, impodva. demolish, or repair any aWCmR
prior 0 its issuance. also requites the applicant for such permit to file a signed sutement
dot he is licensed p....nuo the provisions of the Convector's License, Law (Chapter 9
Sq. Ft. Floor Area
Valu t�g000
(commencing with Section VON) of Division 3 Of the Business and Professions Code) or
that be u exempt therefrom and the buss for Ne alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit.ubjecu the applicant to a civil penalty of
not more Nu five hundred dollars (S5N).
35%2003%.00 '
0 l.no ncrof Nepmpmy.mmyemploycmwithwaguu Neirmlemmpemdon.
Required Inspections
will do the work, and the stmcum is not intended or o0emd for sale (Sec. 7044, Busi• as
and Prefcuions Code: The Contractor; License Law dors not apply ban owner of
property who builds or improvm thereon, and who duct such work himself or through his
awn employers, provided donsucb improvements sae naUnended reoffered forsak. If.
howeveq the building or improvement is sold within ane yens of completion, Ne owner -
builder wi low de hurdrn of proving that no did Iwt Guild or improve for purpose of
saa.).
as owner of the progeny, am aclusively contracting with licensed contractors to
construct time po)cct (Sec. 70d4, Bminea5 and I'md"a ons CwN:) The ean4nebr! LI -
came law docs dol apply to m owner of propeny who Wilds or improves thereon, and.
who contracts for such pmjeeu with a ea torts) Iconud pursuant to the Contractor's
Lkcna law.
p lam ca d S' .B&PCfm Nitro
/j
/ Date
ntr
W R' DECLARATION
I hereby undcrpenally pidurydneofthefollawingdeclamlions:
aveandwi romuinsCerdf amof Conscntiomlf.iuumforWorkce$Compcn-
n, as provided for by Section 37th of the labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensaion Insurance, as inquired by Section
37th of the labor Code, for the performance of the work for which this permit is issued.
My Workers Compensafion Insurance [artier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF FX EM MON FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not W completed if the permit is franc hundred dollars (SIN)
or less.)
1 cenifv that in the performance of the work for which this permit u issued l shall ON
employmy person in any manner sou m bac me su 'act the\ rot Compenudon
Iawsof Californu.
Applicant A+
NOTICE TO APP ter making ( cnifi tion, you should
become subject m the Wo cr's Compenrstion provision the la or Code, you must
comply with such provisiom or Nis permit shalt be deemed revoked.
CONSTRUCTION LENDING AGENCY
I army affirm that there is a construction lending agency for the performance of
the work fur which this permit u issued (Sec. 3ND, Civ. C.)
Lind.es Name
lenders Adders
1 certify Oat 1 have read this application and suss that the aW ve information u
I Mom to comply with all city and county ominarem and suite laws relating to
Wilding construction. and hereby authori¢ mpriumatiives ofthis city to enter upon de
ahavomciamaed propeny for inspection purposes
1)
(We,) agree to save. indemnify and keep humless the City of Cupertino against
liabilidee.judgmenu, costs and expenses which may in any way aecme against said City
inconsequenccofthcgoomgof Nis =mit.
APPLICA U RSTANDS A ILL CO PLY WITH ALL NON -POINT
"
Issued by: Date
SOURCE /J
Re -roofs
Type of Roof
j
Signazu o A icon m=otor Dau
HAZARDOUS M ALS DISCLOSURE
Will applicant or future hull n occupant store or handle hevallous material
u defined by the Cupenin t MuniciP fid Chapur 9.11, and the Health and Safety
Code. section 35533(.)?
All roofs shall be inspected prior to any roofing material being installed.
Yes
a roof is installed without first obtaining an inspection, I agree to remove
Will the apph=ant or future building «.pant ate equipment as devices whichIf
haraldous air contaminants as Jcfnc l by the Bay Area Air Quality Management
all new materials for inspection.
Ren
❑ Yes Wn N4(/
I have mad Ne ImOso us materials mquimmenu under Chapter 6.95 of the Califon
nia Health &Safe Codc, sued 25505. 533am175534.1mikodindthazifthc Wilding
docs oat curt Non' responsiWhy do noddy the occupant o! the
mgairemcn t oatccar.cenifiaear epancy. '9
Signature of Applicant Date
� All roof coverings to be Class "B" or better
owde nl.m i'redasent D.te