07100192 1 CITY OF CUP ERTINO rg ��aYYY
BUILDING DIVISION. PERMIT `f j�>L' � �'yE� �,� <s
i PERMITNO.
BUILotj+rbrr�gR�ss:S DE ANZA BLVD RON PARIS CONSTRUCTION CO 07100192
T'S NAME: - PEII_ISSUE DATE
CEN PATEL 3575 STEVENS CREEK BLVD 01/07/2008
PHONE: SANITARY NO. CONTROL NO.
(408) 296-5926
ARCHITECT/ENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X86 LICENSED CONTRACTOR'S DECLARATION Job Descr1 tion
1 hereby affirm that 1 am liceaud under provisions of Chspmr 9(commencing P
:io, withSection70f1d,ofDivision3ofthaBunn...andPm(essionCade.ardmylfcernuis COMM'L T. I . , ADDING OPENING IN WALL, MERCATILE
<°• in full fame and effect.
f Z Licenu Claza Lle.p NON
�Hq Dam 1 Co.,,utar
qq7W ARCHffECI-S DEC R C2+` STRUCTURAL. COMBINE ADDITIONAL TENANT SPACE
C U 1 understand my plans shall M useJ n public recnNs C,� /U
n
tae� Licensed Proassianal
y OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
O O following mason.(Said..7131.5,Business and Professions Code:Any city of county
which requires a Permit to contract.alter,improve,demolish,our repair any somatom
prior to its issuance.also requital in applicant for such Krach to rile a signed Mammvn
< that he is licensed ptroxmiHothcpmvisioosofthe CommencesLicense Low(Cloptn9 Sq.Ft. Floor Area h Valuation
2 (commencing with Section 7W0)of Division 3ofthe Bottom and ProessimrCentel or
c .- that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects thc applicant to a civil penalty of pt Number Occupancy Type
nut mom than rise hundred dollars(M). 3 5 917 0 01 A.0
Q1,as owner ofthe property,or my smployen with wages a their sale compensation. -
willdotheworkanddeswctumisnotimm�ded or offered forsem(Sec.70s4,Business Required Inspections
and limitations Code:The Contractor's License es Law donot apply to ao comer of q p
property who builds or im proves thereon.and who doessuch work himself or through his
awn employees,provided that such impmroments ere not intended aroRered fareals.IL
however,the building or improvement is sold within am year of compledon.the awour-
builder .will have tin burden of proving that he did Out build or improm for purpose of
sale.).
❑1,a$awoer of due property,am exclusively contracting with licensed conaamrs to
Cownmt the project(Sec.7004.Business and Profession Code:)The Coreacmis Li.
cense Taw don not apply to an owner of property who builds or improves Nemm.and,
who contracts for such projects with a contractor(s)licensed pursuant b the Cantncures
License Law.
❑Ito exempt under Sec ,B&P C farthis ream.
•r
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of penjury one of the following declarasimz .
❑I have and will maintain a Cenifieau of Consent a self-inure far Workch Campen-
ndies,as provided far by Scedio.37W of the labor Cade.far the perfomanco of the
work for which mire Permit is issued.
0 1 have and will maintain Worker's Compensation Insurance,az required by Sada
37W of the labor Code,for the performance of the work for which this permit is issued
My Worker' Com nsait Insuvace carrier and Policy number are:
Cartier. l.0 Policy No.:5rt�-kaLa(a
CERTIFICATED EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
(This it..need nmbccomplmcd if the permit is fora..haratcd dollars(gl(10)
Ims.)
1 certify that in the parfomance of the work far which Nis Permit is fumed,!shall at
employ any poset in any mnnerso az to become subject to the Warxere Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,agar making this Certificate of Exemption.you should
became subjmt in the Worker's Compensation provisions of the Iabm Cade.you most _
,J Z forthwith comply with ueh provisions or this permit Shall he domed revoked.
„'Z„O CONSTRUCTION LENDING AGENCY
[r Ihereby affirm that them is a construction lending agency for the performance of
fYi .>-, the work for which this permit is usucd(Sec.3097,Civ.C.)
W Q Lenders Name
az Lender's Address
1-)O 1 Certify that I have mad this application and solo thM the above information is
W Hcomet.I agree to comply with all city and county ordinances and sum laws mladng m
V building consuuctim.and hereby authorise representatives of this city to enter upon the
W above-mentioned pmpeny fur inspection purposes.
(We)agree to save,indemnify and keep harmlcas the City of Cipeninu against
HfA liabilifles.judgm cos.and experun whichmryin any way scene againtsaid City
C) ",l its
S11LI
ne ofthe gmn !this permit.T NDERSfAND ND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2:1 na EG AT70NS.
/ Re-roofs
Signature of Applint uxamr Dam
HAZARDOUS MATERIALS DISCLOSURE Ty pe of Roof
Will the applicator future building Occupant Moce.cla ndlc hiumNaos motorial
defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
.Section 25532007 All roofs shall be inspected prior to any roofing material being installed.
❑Yes -•—®Na
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit harerdous air contaminants az dcfncd by the Bay Area Air Quality Management all new materials for inspection.
District?
Dy. 0 No
I have mad the haroudcus materiair mquimmente underchapter6.95 ofdre Califor-
n'th&Seat Cade,Sections 25505,25533 and 25534.1 understand that iflh bolding
docs t eu ntly o 4 Nat it b my msponsihility tomiry flue.,ma of the
quite Co. ichmusbcmet 'on.issuaccafaCcrdf amoraapa . Signature of Applicant Date
e All roof coverings to be Class "B"or better
Owner ser authorimda ratC Date