05100210CITY OFCUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMITNO. 05100210
0225 S DE ANZA BLV
'S NAME:
PERMIT ISSUE DAIS
MIKE VARDY LLC
02/07/2006
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDOO ELECTO PLUMS MECHO
LICENSED CONTRACTOR'S DECLARATION
Job Description
I bomb, tUhm that I am limned under provisions of ChaPur 9 (commencing
with Section 7") of Division 3 of de Business and Profession, Code, and my license is
in full Tom and offset.
TENANT IMPROVEMENT
License Class Lt. N
Detw' Common,
ARCHITECTS DECLARATION
1 understand my plans Nall be used as public mmrda
Licensed Pmfeashmal
OWNER -BUILDER DECLARATION
1 hereby efface that I no tempt fmm the ConuactWs License law for de
following mason. (Sudan 703 1.5, Business and Professions Code: My city m=my
which requires a permit to convect. slur. impmw. demolish, or repair any structure
$252784
prior to its Issuance, also requires he applicant for such permit to rile a signed suumenl
that he is licensed pursuant to the provisions of ties Chanson's Liceast Law (Chapter 9
Sq. Ft. Floor Area
Valuation
wassunndng with Sturton 7000) of Division 3 of ase Businessmd Professions Code) or
that he a exempt therefrom and the bash your the alleged exemption My violation of
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Occupancy Type
Section 7071.5 by any applicant for a permit subjects the applicant m • Civil Penalty of
not mare than rive hundred dollars ($5001,
❑ I. as owner of the property, or my employee with wages u Neto onto eompeasadon,
Required Inspections,
will do the work, and die ansmu a is not intended or offmW for talc (Sm. 7044, Harness
and Profession. code: The comaxwes Licence Law does Out apply in an owner of
property who bulldsar lmpram mhamon,end whodoessuch work himselfor through his
awn employees, pmvlded that such Improvements ase notimended mortared for Wa If.
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however, the building or improvement Is said within arc year of completion. the owmr.
W Ilam will ave the Widen of proving that K did not oda an Improve for purpose of
au.).
❑ I, as owner of property, .Bead confessions with contractors i.
t!
construct the project (son. 7044, Boniness and Profusions code:) The Conuxofa Li.
ct ss and :) The
D
Cense law does noI "PIY m an owner of pro ny.wW Wildaof impmm thereon. and,
who mnncu fm axh Projects with s eenuacrort,) limned psnum aNeConuanoM1
Lkene Law.
❑lamexeml m. B Is P C fooight 7.
Dam
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"W(A)R//KK�E//'S COMPENSATION DECLARATION
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I hereby a1fla-6 ser penury of perjury ane of On following declarations:
❑ I naw and will b i fo Wmkefa
cation, for sea the
Section 7700 of the labor Code. (m she performance of Orc
provided for Sudan 3eu of the Labor
r mi
wok for which this permit Is issxd.
❑ 1 haw and will maintain Worker's Compensation Insurance, m required by Section
5700 of the uhor Code, fm the performance of the wok fm which Nis permit is added
My Warton Compensation Nurse eanim and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crow maim need mt W mmpued Ude p stall w franc hicubmidollus(310()
or lm.)
I certify that In Nc Pull eo of the wart qr who, thw permit is iuoed, I shall at
employany parson erxuo times sotto the Work, 'Comp tin'
Laws of Califo
Lam of
NOTICE TO APPLICANP. If, a r eking hr. Certificate o •x mptto . you should
become subject m du Worker's mimmation provisions of t e Lihos mac, you must
forthwith comply with such provisions a, this Permit shall be deumea revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Nem h • mammalian lending agency far de perform. of
the work fm which this permit Is issued (Sm. 3W7, Civ. C.)
LendersName
,
Leudet, Address
1 unify that I haw and this application and suss that de show infomNm Is
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conn. l agree to comply with all city and county ordinances and sate law, totaling in
Wilding convection, and hemby authorin representation of this city in cner upon the
movcmemioed Property for Inspection Puryaes
(We) agree or few, indemnify std keep humlcss the City of Cupenino spins)
llabilides, judgments, costs and expenses which may in my way sense against aid City
to consequence of the granting of this Permit.
APPLICANT UND R DS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Z_ , Date G !,f/ Ca
SOURCE RE ONS.
Re -roots
Type of Roof
sig ata AP ¢set o ore
H AR OUSMATERIALSDISCLOSURE
WIIINeapplic of fouve Wilding mcupanlRoe of NnNclwudow maeriat
lined by de CupeNno Municipal Cade. Chapmr 9.13, and the Health and Safety
Section 25532w)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ONO
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupam use egmpmmt of devices which
unit human. air cm unimats as defined by we Bay Ma Air Quality Management
all new materials for inspection.
District?
❑Yes 0 N
I haveread the haardmsmateriats requirements underchaper695af tW Collor.
rah Health BSaw"C Sdtimu25s03, 25577 and 255N.ImdernM Nstifthe building
dam note• unan Nat Itis my nsihilily o notify IM oceup n(
require ichmuu a pd.,iaaa aarttoarheseafampuu
Signature of Applicant Date
All roof coverings to be Class "B" or better
w , m aathadya at a
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