04010122 CITY OP'CUPER"fINO
BUILDING DIVISION PERMIT CONTRACTC)R NFORMATIO.,N
BUILDING ADDRESS: RYMIK DEVELOPMENT """"'04010122
-go HAZEIRROOK
MS NAME: PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 0 0 0
u0o LICENSED CONTRACTOR'S DECLARATION an"IIXJob Description
UC 1 thereby affirm the,1 am littnsed under provisions or Chapter 9(commencing
U with 5caihq of Division 3 of Ne Business and Professions Code.and my license is
,to
„ L License
REVISION--IN HOUSE USE ONLY
J�? Licenx Class Lias
;mac Dam C°n'rserer NO NEW PERMIT ISSUED/ORIG. #03030037
££,i ARCHITECTS DECLARATION
C< 1 understand my plana shall be used as public mem s
JyU
GG Licensed Professional
Q 3 OWNER-BUILDER DECLARATION
4<y 1 hereby affirm that I am exempt from me Contmmo's License Law for the
0o following reason.(Section nn 1.5,Business and Pmfcbions Cods:Any city or County
;e m which mquira a permit to consumer.atter,improve,demolish,Or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
< thu
at he is licensed pursuano the provisions of tc Cimaelm"License law(Chapter 9 Sq.Ft. Floor Area Valuation $0
y�D (commencing wit Section 9UO07 of Division 3 of the B usincss and Professions Coded or
y $ tat he is exempt Ihemfrom and the bash for the alleged exemption.Any violason of
Section 9031.5 by arty applicators fon permit subjects to applicant to a civil penalty of APN Number Occupancy Type
not more tan five hundred dollars($500).
b 1,ss Owner of the property,m my employees with wages a their sole compensation. 32655031 . 00
will do to..,it,and the struaurc isnot intended tar offered for sok(Sec.7W.Returned,
and Profasmtu Code:The Conuanori License law docs not apply to an Owner of Required Inspections
pmpeny who builds or improws Common,and who does such work himself or trough his
own employ=.provided that such improvements arc not invaded or offered for sale.If,
however,Coe building or improvement is sold within one year of completion,the owner-
builder will haw the burden of pmving that he did ned Wild or improve for purpose of
salt.). /
0 I.as owner of tc property,am exclusively...bacon,wit licensed cannacmrs 1. \O\
construct the project(Sec.7W,Business and Professions Cade:)lye Contractor's Li- .. \
cerde law Ems not apply to an owner of property who Wilds or improves Lemon,and m�
who contracts for such projeca with a contractor(s)licensed pursuant to tht Contractors V
License law.
❑1 am Par"
untl Scc. .B&P for ti rcazon
I 'tDam
W RKHRS COMPENSA DECLARATION
444
I hereby affirm under penalty of perjury one oftefolwin Iarations:
rl I have and will maintain a Certificate of Cnvxnt to se r.iaum but Worker's Compere
atibn,.provided for by Section 3700 of the LaWr Code,for Coe poor....Of Me
work for which this permit is issued.
1 ban and will maintain Worker's Compensation Insurance,as required by Section
3900 of Coe labor Code,for 0e-performance of to weak fm which this permit is issued.
My Workers Compensation Insurance Omer and Policy number am:
Cartier: Policy No.:
CERTIFICATE OFEXWMON FROM WORKERS'
COMPENSATION INSURANCE
(This satin iced not W compleeJ tide permit is forbnc hundred dollars($1(X))
tar Mss.)
I cenify Nat in the pc,form...C of the work for which this permit is issued,I shall not - -
employ any person in any manner an as to become subject p to Workeri Compcnadem
Laws of California.Dam ..
APPlicant
NOTICE TO APPLICANT:If,after making this Ccri ficae of Exemption.you mould
Wcome subject Io the Worker a Cumpcaminn provision,of the LeWr Code.you..at
.J Z forthwith comply with such provisions m tis permirshall W deemed invoked.
zO CONSTRUCTION LENDING AGENCY '
I-w Ihereby affirm tat there is a construction lending agency lire to performance of
a > Ne work for which tis permit is issued(Sec.XW.Civ.C.)
W Q Landeh Name
g5. Landers Address
VQ 1 certify that I haw read ti,application and MM,tat de above inumtuion is
ly r coned.I agree Io comply with all city and county mobord s,and state laws relating in
C U building construction.and hereby sutorim mpmxnmiws of this city to enter upon Coed
r W above-mentioned property for inspection purposes.
(~Oa (We)agree m save,indemnify and keep tombless the City of Cupcnino against
liabilities j idgments.costs and expense,which may in any way acmuc against said City
U Z APPLIC eanCeof Me UNDERNf �r
STADNWILL COMPLY WITH ALL ONP INT Issued by: Date
SOURC EGULATIO G
Z
L aq Re-roofs
Sig m.fA,,dmdoVC. header Dam
HAZARDOUS MATERIA4S.01SCLOSURE Type of Roof
Will to applicant or future building Occupant store or handle havaNuu,material
dcfincd by to Cupertino Municipal Cade.Chapter 9.13,and ted Health and Safety
otic.Section 25531(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yea CQLN.
Will the applicant or future building occupnt use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by Com Bay Arta Air Quality Management all new materials for inspection.
District?
D Yes QNn
I have read the bevaNnus materials requirements under Chapter 6.95 of Coe Califor.
nix Herlds&Safety Code,Sectio.255)5.25533 and Z5534.1 undersand deal if the Wilding ..
docs n cumen" he mnanr.the 1 h my responsiM1ility m to.1. tc cupenr of Nc
requ eOawhfan de etp rteis,aaneenracen;re nfgec .acy, O Signature of Applicant Date
OP n onamnrivedagen, l D�,m All roof coverings to be Class "B"or better