06020016 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,I�COVTRACT , INFORMATION ;
BUILDING ADDRESS: PERMIT NO.06020016 6020016
20395 PACTFTCA DR
OWNER'S NAME: PERMIT ISSUE DATE
PACIFICA SUITES OWNERS ASS C
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ipo LICENSED CONTRACTOR'S DECLARATION Job Description%mF I hereby affirm ohm l arm li¢ncod under pmvisiots of Chapter 9(commitment,
:IW with Section 7")of Division J of the Basin.and Pofmomes,Code.and my]fee is
'.3„ infail ror and do
rv. REPLACE AIR CONDITIONING SYSTEM
LicemnClaaa Lip.8
NEEDS BUS LIC A/C SERVICE & DESIGN CO
r Comb
Dau! Con u
ARCHITECTS DELL DECLARATION
f¢� I understand my plans shall he used as Public records
>yU
C
Liccnud Professional
3 OWNER-BUILDER DECLARATION
M 1 hereby alTmrm mol I am exempt from the Conoracmes License Law for the
O O following reason.(Sccuon TD31.5,Business and Professions Code:Any city or county
'2E which requires a permit to convect altar.impmw,demolL h,or repair any structure
prior to its issuance.site requirta the applicaut for such permit as file a signed statement
i C Nm he is licensed pursuant to de,provisions of the Contractor's Uumic Law(Chapter 9 Sq.Ft. Floor Area YalU�{1r9�0 0 0
ra-O (cmnmencing with Station 7000)9 Division 3 of the Business and Prafessimu Code)at
i 9 that he is exempt therefrom and the basis for the alleged aempdoa My violation of
section 7631.5 by amy applicant for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
mom mom than five handled dollen(35W} 36940030 . 00
❑I.uowmr ofth propeny,mmy wployeu with wagau ue'v sWe mmpcnuuon,
will da tie work and de he Cont u tors LMed or caw do al-I a(See.7054,Bo-I Of
and property
ou Cade:The vesthernam Lice ho law don oat apply lf rt owner is Required Inspections
property wha builds provided
that
mh improvements
who dmssmhwmk himself edthrough his
ownemployee,p Wilding
or imam veruch imPro id wit artmyour of completion.
m leerM fm sola If.
builder .Nebuil tha or improvementusoldwithinow your ofcompletion.meowur-
builder will have Uta Horden of proving that he did not build or improve for purpose of
talc.).
1.u owner of me property.am aclmively canuacting with licenced Contractors to
ash uct the project(sec.7044,Business and profestiam Cade:)The Contractor'.U.
cense law docs not apply m an Owner of property who builds of improves memon,and
who contracts far such projects with a contrxtar(s)licensed pursuant to the Continences
License Law.
ulama pl under See BBPCformis
OWmr Date �1
WORKERS 0 A ON DEC' TION CJ/
1 hereby aRim under Pamully of Perjury rota of the following dalaratiomtc (�
❑1hawaMwillmaintainaCe rssawof Cowatioulf-alumfor Wof sCompcn-
ann,u provided for by Section 37M of the labor Cad,for thc performance of the
worts far which this permit is bound.
❑I have and will maintain Workers Compensation In ora et,u required by Section
37W of the labor Code,for the performance of the wart for which this permit is Issued. '
My Workers Compeuauon Insurance carrier and Policy number art:
Carrier. Paliry No.:
CERTIFICATE OF EXEMP ION FROM WORKERS
COMPENSATION INSURANCE
(Thu uctitn teed not lc completed ifihe permit is foranc hunNMdollus($100) a
or leu)
I certify mat In me Performance of �//which mit Permit I.issued.I ensaduall am
employLaws
C3 perspninany manner o c b' a Workms'Compcmation
Laws a!CalifArtda.Date •A
APPl CF To' c d r.
NOnCE TO APtlSe Work f.atom ma esti mit Cisions of th c prion,you should
becomesubject
comp y the Wahero Compensation provisions of de labra Code,you most
.J O forthwith comply with such Provisions or mit permit shall M deemed revoked.
„Zj CONSTRUCTION LENDING AGENCY
[-+ I hereby affrm thm there is a construction lending agency for the performance of
Ili > the work fm which mit permit is issued(See 3097,Civ,C.)
GUndoes Nurse
;z)z Undoes Add.
U Q 1 certify that 1 have read this application and lute mu the above information is
U, Hcomm.I agree mom
empty with all city and county ordinances and state laws relating to
C V building construction,and hereby authorize mprtacnutiws of this city to enter upon the
>'a above mentioned propcny for inspection purposes.
(Wer)agree to save,indemnify and keep harmless the City of Cupertino against
i to
liabilities.judgments.cuts and expetuci which may in any way ansae agaimt said City
V z in consequence of the gnnung of this permi. G
^ APPLICANT UNDERSTANDS D W MPLY WITH ALL NON_POIjT Issued by: Date
SOUPA REGULA'f+ONS. .
!;PD*. Re-roofs
Sgnaurt of Apph u'Canuumr
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant ar!utero Wilding acupantsta a of handle hazardous material
u dcilned by the Cupertino Municipal Code.Chapter 9.12.and me Health and Safety
Cade.Section 25532(x)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes l4aa
Will thea Ileam car min building occo ant est If a roof is installed without first obtainingan inspection,I agree to remove
pp e P Area
Air Dm ir dMana whim P g
emit e'? air contaminants u dcOned by the Bay Arta Air Quality Managcmcnt all new materials for inspection.
Dista n7 9
❑Yea IyfJa '
I have rend the hazardmumaterials requirements underchapo:r6.95 ofthe Califon
nit Hcalthds Safety Code,Secmiam 25505,25533 J 25534.I umdcrsmnd thmifue Wilding
Jura not conically haw a emm,mat i iIiiy m noul'y Nc accupul of the
I. tswhimnma berm pfiof omit taafaow (I_IO Signature of Applicant Date
Owner rami' nmi.d.,ern, ��� cap(_ 140f
�1 All roof coverings to be Class"B"or better