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CITY OF CUPERTINOe
BUILDING DIVISION PERMIT
lkC�£ RACTOR-MORMATI0IV
ADDRESS:
NOVO CONSTRUCTION
PERMIT No.05110085
LUU�[DING
RESULTSWAY
ER'S NAME:
PERMIT ISSUE DATE
GROSVENOR
1042 HAMILTON COURT
ii/ir/9,005
IF:
SANITARY NO, CONTROL NO.
(650)701-1500
ARCHITEC )ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
al 1 am licu,d under pmrovius of Chapter 9 (romm,n.in{
T berth, affirm Nm
with Schon 70(10) of Division 3 o(the Busm. and ftiessiou Co ki.md my license is
kfull raro ceded 7gJODa
REVISION -DELTA 3
�It cnuactar 6' o [.,..an..ccl,a,...
Lic.Date
NO NEW PERMIT ISSUED/ORIG. #05090217
It/
ARCHITECT'S DECLARATION
'
I understand my plans shall bo used as public mcoms,
Licensed Pmfcnsional
OWNER -BUILDER DECLARATION
1 hemhy aRrm Nal I an eumpl fees We Conuzcmfs License Law for than
following mason. (Section 7031.5, Business and Professions Code: Any eily or county
which requires; a permit to convect alter, improve, demolkh. or repair any swewrt
! prior m its issuance. aiW mquines the applicant farsuch Permit o ftie a signed su¢mcm
We Contractors ueemse Law (Chapter 9
Sq. Ft. Floor Area
Valuation $94
the le is licensed pursuant to Weproomoti of
(commencing with Salon 7000) of Division 3 of the Business =it Pmfeadon, Code) at
• that he is ac cmpl therefrom and We but, for the alleged exemption. Any violation of
ppb] mber
N8
Occupancy Type
Section 7031.5 by any applicant for a pvmil subject, We applicant to a civil penalty of
ant mart than five hundred dollars (ssoW).
3 57 2 0 0 42.00
❑ I.uowcur o(ttie property,amY wployw with wagcauWe'v sok campenution,
Required Inspections
will do We woh and the swctum is not ktendod or offered for mice (Sec. 70x4. Budrcv
Nd Profession" Cade: The Commc als LI¢nY Law coca MI apply m N Owner of
l C
Property who builds or improves Ihemon, and who does such work himulf or through his
Own employee, provided thttsah improvement, are cul intended aolfered formic. If.
bowever. We building or improvement is sold within au Year of completion. the owur-
builder MO Nve the burden of pmving that hei did cul Wild! in improv fa purpose of
see
A \
C] 1 . u owner of exclusively contracting with fie convectors m
❑
\�^/
cummu ct Sm. 704 , Business c C LI -
Cade:) The Cst ft...
nYwbo builds or improves thereon. and
occurs it des feel pply into, antroand Prof' . Wilds
taw coca cot apply m own. of
F
(a such Pmjcsss with acanvantm(s) w.edpunwmmN. Conuu7als
who , Cacti
Lic'. Lacca
[.icons, taw.
❑Tem exempt send. See ,BkPC for Nu reason
. own
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Per111Y of perjury one Of Ne following delaruians:
I has and will maintain a Conifrate of Co.., to self -insure far W.kefaComport-
sa'On, u provided for by Section 3700 of We labor Cade. for Ne peAarmana of the
wart far which Nu permit is issued.
❑ I Mve and will reaimak Wortef. Counpcnation frommu ce, u required by Session
37110afde Liber Code. far We peRormance of Ne work far which this permit k issued.
'
My Worker, Compensation Insurance carrier and Policy numC� r art:
limier. policy Na.: 7 �Y 9
CERTIFICATE OF EXEMPrTON FROM WORKERS'
COMPENSATION INSURANCE
(This scion need no, he completed if We permit is force. hundred dollars (5100)
or loss)
I certify Not in We pe,formane, of Nc wort for which this permit is issued. )shall nal
employ any person In my converts u in beam, subject to WC Worked CMnpensum oo
'
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making this CeniOcate of Exemption, you should
baane ,.bj= in the Worker's Compensation provisions of N. Labor Cade, you muse
' forthwith comply with such proNdons OF Was permit shall W dcemW mated.
i
j CONSTRUCTION LENDING AGENCY
1 botchy thi Net Were u a agency for No Performance of
ch ed tScc.30 7.Cl,lending
' the work for which Nu permit u i,aucd (Sec. 7097, CiC.)
L Name
Ms
Lcndch Address
I cestify that I love read this application and suite Nu We above information is
' correct. T agree 10 comply with all city and county ordinances and state laws rtkting to
building coneuuction, and hcroby amhotiu representatives of Nis city mentor upon the
above-mendacud property far inspection purposes
(We) agree to save, indemnify and tap harmless the City of Cupertino against
Iiabilidm judgments. cow and expe"v' which may in any way aerue against said City
in consequence of the granting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date //— /0/- D 0'—
SOUR REGULATIOrys.,
Re -roofs JL
Type of Roof
j [.4&vr \ A'",c 11/16/oS
Signature a(Applianvcann>noor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant stem. handle havallous material
as defined by the Cupenina Municipal Cade. Chapter 9.12. and We Ho1N and Safely
Section 255324)7
❑Yca PMOAll
roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will Nc applicant or future building Occupant use equipment or daicca which
omit havaNem air contaminants u defined by No Bay Area Air Quality Managcmcot
all new materials for inspection.
D Wic{?
❑Yn
Ib mal Ne hvaNsmsmateriais mquimnmw under Chapterh.95afNe Califor-
niaHcalOkSafclyCadaSmiom25505,25533and25534.1undc dNaif Wm building
dao riot curtcnllY how a tenant has it k my tespamihility m cutifY Nc oaupmt of Ne
mgoimmcnu which teas be , toissaane a fac.ulatmafct.pancY.
Signature of Applicant Date
d'c""" 11 /I (_lvS
roof cover
All f in s to be Class "B" or better
g
Ower er aoNarncd agent Date' '