05030123 CITY OF CUPERTINO ^
BUILDING DIVISION PERMIT ' C0IVTRA@1OR�YNF'()ItMATION
ING ADDRESS: NOVO CONSTRUCTION """'05030123RqUT.T.q WAY
OWNER'S NAME: PERMITISUEDATE
NOVO CO
PHONE: SANITARY NO. CONTROL NO,
(650) 701-1500
CHITECf/ENOINEER: BUILDING PERMIT INFO
BO EO PL=S O
30� LICENSED CONTRACTOR'S DECLARATION Job Description
it V 1 hereby affirm Net 1 am li¢iucd under provisions of Chapter 9(commencing
<� with Section 7000)of Division 3 of to Business and ProfeWnns Code,and my license is
LmnmCIAa ����� REVISION-CONFERENCE ROOM
—�Z Lleene Cl l.ic.i
DoteC.omeror V IN HOUSE ONLY-NO NEW PERMIT
ARCHrIECrS DECLARATION
Iunderstated myplans ahallbemedas public records ORIG #05010040
w Licensed Profeatlonal
to OWNER-BUILDER DECLARATION
N
Si 0 I hereby.(Seco 1 am exempt from the Contractor's e:LicenseMy c taw for the
O�O� which ng ream.(Section=ItnU I3,Business and Improve,
de moll Cade:Any eery or county
which requires un permit re construct,M aper nt fortes,demolish,or e a sig any evmwro
�Z4„a
prior uiuuensedpalaurequlma Me Applicant for Inchpenmin Bleadgaetlsutemenl
�< Bommencing wis punuannthc of Division
3 We ConuaceKWaneelaw(Chaprm9 Sq. Ft.Floor Area Valuation
3
that
(commencing exemish pt
70nd of DivuVonr th aleged essand
on.mvi lame)or
But be 4 exanpt Bemfrom and Ute buts for the alleged ewnption.Any violation or 0
Section 7031.5 by any applicant far a parents subjects the applicant to a civil penalty of APN Number Occupancy Type
not more Nen five hundred dollars($5001.
❑I,uawner of Ne propeny,mmy wplayea wlN waguaBoeir Ink eompcnution,
will do Ne wads,and Maswctuoe is notinunded mallard for Wo(Sec.7W.BusinessRe Required Inspections
and Profosdoa Coal Ther Commerce,License Law don,ant apply u an ownm of q p
property who Wilds orimpmtes human.and whorl«,such weak himselfosthroulh his
Own employees,provided that wen Improvements arc not Intended aroQeud for ale.If.
however,the Wilding or improvement is aid within ane year of completion.the owner
builder will have the human of pmving that be did not build a improv far purpose of
am,). Off,
[31,as owner of the property,am exclusively contracting with licenced contrean e
construct the pmject(See.7044,Business and Proroaioos Code:)The Com s cur's Li.
cense Law does not apply in an owner of property who Wild,or Improves,demon.and •�..i�
contractsatar
for such pmjccu with a contr (e)licensed pursuing us the Cantreloea \)
ee L.W.
am uempt under See//'' .B A PP C_far`Bds—w
:r00I
er�D CQ41, vds11(ly Dau
WORKER'S COMPENSATION DECLARATION -'
1 hereby million under panalty of perjury oro of the following declarations:
Mw end will maintain.Cer00eate oFC...,a self•imum for Worker's Camper-
a.
As provided far by Section 3700 of the labor,Code,for Me performance of the
for which this Permit Is issued.
have and will maintain Workers Compensation Insurance,a required by Section
3700 or the labor Code,for Ne performance of she wah for which this Permit is laved.
My Workees CO.pemation lammed artucr and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
CITU section need not be completed lithe perm h is farm hundred dollars(SIM)
arias.)
1 anify that in she performance of Ne work for which this permit is issued.)shall nm
employ any person in any manner an a in become abject to the Worken'Com mmation
Lowe of Cmtfomis.Dau
Applians
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
become subject to Be Worker,Compcosation previsions of the labor Coe,you coup
.Z foMwith comply with Inch provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
H1 hereby affirm that Nen Is a construction lending Blowy for the performance of
Cil
the work for which Nu permit Is bound(Sec.3097,Cry.C.)
W�0 Lendees Num
a Z Lender's Address
U0 I mnfy that I how read this Application and,tate that the aWve Information Is
U, ^ tamer 1 agree m comply with all city ad county ordinances and sum laws mating a
OE building construction.and hereby authorize mpmanullws or Nlwity to dour upon Me
` W ahavcment anrd property for iapectim purposes /
(We)Agree to ave,indemnify and kap harmless the City of CYPeBIm Ailing /
Uin liabilities,judgmcnss.cons ad expenses which may in any way seem,against aid City .
7 in consequence of Ne grating of this perrnil.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO
_]"?Aft.. c, oc Re-roofs
Signarure of Applice.UConueetos Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII Ne applicant or(.turn building occupanunro ail handle herandow matedsi
dcRned by Ne Catamount,Municipal Code.Chapter 9.13,and the Health and Safety
Code.section 25732(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes W.
Will the applicant or furore Wilding Occupant use equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haamoa air contaminants As dented by the Bay Area Air Quality Management all new materials for inspection.
n7
❑Yes 134m
1 hen mad the haawdous mandate requirements under Chapter 6.95 of the,Caairor.
nes Health&SaroyCodc,Sodom 35505,35533 and 25534.1 undcnund then lithe Wilding
dues cot currently how a tenant,Nu It is my rapoaNility m rosy the occupant Of the
requirements which mug bemetrwia.anearacn(kauafOccopoey. Signature of Applicant Date
M��I All roof coverings to be Class"B"or better
Owner ter amhadved agentnt Date