05110036;s
CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
PINN BROTHERS CONSTRUCTIONS
05110036
oi449iiA4hb4E:N DE ANZA BLV
PERMIT ISSUE DATE
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SANITARY N05 31 2® LNO.
ARCHI' ECTYENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARA71ON
lb Description
o P
d under provisions of Chapter 9 (commencing
1 Wmby anirm that l am licensed
wish Suetion 7(00) of Division 3 of tie Business and Prafasio. Code, and my license m
in full forte and affect.
Imo Lle•s
REVISION --CLARIFICATION ON MEASUREMENTS
Data 7t�
Data
ARCHITECTS RATION
NO NEW PERMIT ISSUED/ORIG. #$05070112
1 underuand my plans shall he used As public records
Licto ed PrOessioul
OWNER -BUILDER DECLARATION
1 hereby Affirm that 1 am exempt from No Convector's Licenm Law for the
following mason. (Sectian 103I.S. Busivas and Profession; Cafe: Any city m county
which requires a permit to ennMc4 attsr. improv, demolish, or repair any structure
prier in its inumess. Alan requires the applicant for Such permit to file asigned sWement
License Law 9
Sq. Ft. Floor Area
Valuation
Thu W is licensed purmant to the provisions of tho Convecmes (Chapter
the BusinAnd Professions Code) or
Business 7000)
Division 3
$80
(commencing with of of
that N is exempt thezefroly and the basis fa the alleged exemption. Any vioutino of
APN Number
Occupancy Type
Section 703 1.5 by any applicant for a permit Subjects the applicant to a civil penalty of
Act mo. than Rw hundred dollars (S501.
D I, a Own. of the pmpmy, m my employcn W W w•agu u shebanlesampensadon,
39rl 006A 0 C)
Required Inspections
willdo We work, and the suaaure Is netimanded.offered foruu(Sm. 7044, Basircn
and ProfaWme Coda, The Commutor's License Law does ant apply 0 an Owner of
q P
nomertyWNWIIds.kept. dmeon. and Whodessauch Work himself. shurgh his
'
own employ=, provided Natsueh improvements Am not intended Warrens! forsele. H.
however, Be Wilding Or improvement Is Sold within oro year ofcompletim the owner
Wilder veto have the burden or proving that ha did out Wild At improve for puryose of
uilde
/ \
Cv—
D 1, AS owner of the pmpMY• am uGuSively cOWISCI nl with licensed mnuaeton to
(1
commot the project (gee. and Professions Code:) Th Cmva
en, nd
roue law dots not apply to im own. of progeny who Wilde or Improves tietmn, and,
o an mer of
`
who aeu for projects with a conllet^fD) licensed pursuant Bo Canvacmr's
/V\
L s ILoW.
tonnce
0 i am vamps undo Sa. . B 8 P C f. this mune
Owner Dam
WORKER'S COMPENSA71ON DECLARATION
I hereby tM m under penalty of perjury, one of the following dedentlooa:
w and WO msinWn • Certificate of Consent to self-losure f. WOrk e.0 mpen-
n, As provided far by Section 3700 of Ue labor Cade, for the performance of the
al
week for which this permit is=us&
Ofhaw and will maintain Workch Compensation Iu.mm, u required by Section
3'100 of the LAW, Code. Fat, to performance of she work rw which Nis permit u isued
'
My Worker's Compensation Insumom carrier and Policy numb. ate:
,
carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rDlhsmik n need not W aropleted If tit permit Is forone hundred datlan (SIOU)
As kat)
I (entry that In the puform-no of the work for which this parmit is issued. I shall not
employ anypenon in my maocan, AS At become subject to the Worlms' Campenudon
Lows of Caliromis Dau
Applicem
NOTICE TO APPLICANT: IC after making this Certificate of Exemption, you should
become subject to the Worker'! Compensation provisions of the lab. Cade you mal
forthwith comply with such provisions. this permit shall W deemed rooked.
CONSTRUCTION LENDING AGENCY
I hereby aMnn TNI them It. construction lending Agency for the Performance or
She work for which this permit is issued (Sec. 3097, CW. C.)
Lender's Name
Lender's Address
I certify that 1 haw mad this application and sue that the Above information Is
comma. I Agra to comply with all city and county ortimmces and sum leas muting to
Wilding convection, and hereby authorize representatives of this city to mmr upon the
above-meati.md property for inspection purports
(We) agree to save, indemnify sato kap humlus the City of Cupertino Against
IlablliUesjW gmmu.c.0 and upr"•"• which may in my my Attroe against mid City
_
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS ND WILL COMPLY WW ALL NON -POINT
Issued by: Date
SougryegEc� T7ops../}a Q //i7. S_3/
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Re -roofs
Type of Roof
mxao�-••O'1
SignuVum of Appli Dam
HAZARDOUS MAtBRtAfS DISCLOSURE
Will do applicant. future Wilding Occupant use. handle haurdous material
AS dermad by Be Cupertino Municipal Code. Chapter 9.13. and Bo Health and Safety
Cam. Samez553z(aj7 �,�/
All roofs shall be inspected prior to any roofing material being installed.
DY. $No
_Wilding
If a roof is installed without first obtaining an inspection, I agree [o remove
Will the applicant or tf mumomupmt use equipment or devise which
harsrdnus air conuminmU ns Oned by Bre Bay Area Air Qusiity Management
all new materials for inspection.
untT
❑Yea u
Ihaw rout she hats At materials requirements under Chapmrh.93ofthe Glifor-
^uHealth@SafnyCotle. 'am25505.75533 uu17553d.l utgMund We Irma Wilding
done not culmndy he a ton Nu it Is my msponsihility to netify Ule OCCupanl of the
req m tswhk too ammorac 'e.soofOccupancy.
Signature of Applicant Date
- 3/
All roof coverings to be Class "B" or better
'
Owner. anthodsd agent Dam