05100020300
CITY OF CUPERTINO
'BUILDING
CONT R TNPOR�MA'rION -,�w
DIVISION PEF MIT
,C
BU ILDING ADDRESS:
RP,qIJT.T,q WAY
NOVO CONSTRUCTION
PER""ND05100020
.R'S NAME:
PERMIT ISSUE DATE
GROSVENOR
3042 HAMILTON COURT
1Q/Qq/2nnc;
E:
SANITARY NO. CONTROL NO.
(650)701-1500
ARCHIIEC TINGINEER:
BUILDING PERMIT INFO
BO ELECT PLO MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hemby affirm that 1 am licensed under previsions of Chapter 9 (commencing
with Section 70111)of Db,hw.3 of dte Business aha Pre(cutuns Code, aed my It... is
mfull fomeandeffect I�
DEMO -1ST. FL. /INTER. WALLS/CORRIDOR,
LicenseCluA Llc.g
Dave e— v Canu.ctar t+w v.c
OFFICE SPACE
DECLARATION
d u public records
I undersand my plana shall neARCHITTEed
FINSLE®
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from we Contractor's License Law for the
DEC
(allowing reason. (Section 7(D 1.5, Business And Professions Code: Any city or county
eX
900
which requlm a Permit w COMUL" Allo, imPmw, doo nlim. w repair any suucwm
C
Prior w its issuance, also requires the applicant for such Pemiuo file asignedmoment
Ow Commcwr's Licame Law(Chapter9
S Ft. Floor Area
q �y4ro 00o
that he is licensed pursuant to the roviaions of
(commencing with Smtion 7(00) of Division 3 of we Business and Prafessum Coda) w
Will
Ihn he ts eampt therefrom and we basis for the Alleged cumption. My violation of
j�Valuu*
APN Number Obcupa yy'Cype
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more Nan Ow hundred dolim (SSMI,
35720042.00
❑ Luownerk the property, employees withwguutheir ante compenudom,
Required Inspections
will do Newark,ande;I=Cuntsnot 44.
r is
m's Lidedo LawdAfanai Apply M of
An
and PmfeWans Cade: Tha Conuacmn. License Law doss rot apply lf rt mumu
9 P
is
who and who dossouchwwkhimxlftertluaugh his
s,iproorireproveschemo,
own em swhimprevennmta me not Intendedor
ownemployceuiprovided for sale.own
llmm. r.
however the buildingheImprevemant bsold withinione year of owner -
pr
e improve
MB bAw the buNan of proving cut he did net Mid w imprew fes purpoa of
"is).
sseJ.
0 1. as awxr of we property, am exclusively contracting with licensed contraction to
come= are project (Sec. 7044, Business And Profession Code:) The Commem's U.
come Law does not apply w an owvmr of property who builds or improves daemon, and
who contracts for such projects with a canuacwr(s) licensed pursuant in the Contractors
License Law.
0 lamuemptunder Sm. ,B&PCfordaiwAw.
Date
WORKER'S COMPENSATION DECLARATION
1 hemby affim under penally of perjuryane of the following dalmdom:
aw and will mainWn a Certificate ofConsetw self-Insom forWorkersCompon.
, u provided for by Section 3700 of we Labor Code, fes du performance of wefor
ICAMer.
which dais permit le is od.
aw and will maintain Workers Compensation Insurance, u required by Section
of the Labor Code, for Ne performance of de work for which this permit is issued.
orkers Compensation Insurance carrier and Policy/num�bber am:. p
Policy No -gym IS2O'T'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(lbls section sued not Mount if the permit is fwasuhundred dollen ($100)
or leu.)
1 certify Not in the performance of the work fes which this permit is issued, l Nail nut
employ any permn in any merman As w Occame subject to we Wormd Compensation
Laws of Calif rod.. Date
Applicant
NOTICE TO APPLICANT: If. after making this CedHkate of Emmp ion, you should
became subject to we Warsaw's CompmuNon provisions of we LAW Code, you masa
forthwith comply with such provision or this permit shall be, deemed mvnked.
CONSTRUCTION LENDING AGENCY
1 heresy affirm war wen u s ending agency for the performance of
ed (Secti0
' cte wash for which was permit Is issued (Sec. 7097, Civ. C.)
TendeM1 NAme
_
Lenders Address
i 1 cenify that I have read this Application and sum that we abate Information is
' mrrmz 1 allow to comply with All city and county ordinances and sum Lam mlating in
Wilding construction, and hereby auwarin representatives of this city to cora upon we
I shove -mentioned property for lmpecdon purpmu.
(We) agree in save, indemnify and keep harmeso des City of Cupertino against
liabilities. judgments. cress and eapamu which may in any wry amus against rid City
In APPLICANTUNDERSTANDSAof the granting of IDr
ANTUNDESTADS N WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUu/REGULATIONS
Re -roofs
Type of Roof
Aaryl 1g'��to-5-C>15-
Signurco ApplicanUConuac r Dew
HAZARDOUS MATERIALS DISCLOSURE
Will dao applicant or rulum Wilding Occupant store or handle ha=hme material
Med by the Cupertino Municipal Code, Chapter 9.13, and we Health and Safely
.Sued..35533(.)7
All shall be inspected to any roofing material being installed.
Oyu ONo
roofs prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant of future building =upon[ use equipment or devices which
emit haurdou sit movements u defrncd by the Bay Ana Air Quaiity Management
all new materials for inspection.
District?
0Yes ONo
I hew read the huardnus materials requirements under Chapter 6.95 of dw Califon
hie Habb& SafetyCode, Sections 35505, 35573 and 35534.1 undemmnd that if the building
dao not currently have A mnsa, that It u my MPGOUNIlly w nodry the OceuPanl of the
requirements which most b2e met p'riorwissuancc of a Cerulkac of Occupancy.
Signature of Applicant Date
'ti.rFar 6!� 4-5-05All
roof coverings to be Class "B" or better
Owner or suwodmd qem new