05030299 CITY OF CUPERTINO x >. oma .at�, *Y•a R �`4 ` '" 'd^'r°''^
BUILDING DIVISION PERMIT "CO TR:�.CT',MN)�'ORM.A.TTpN
[NO ADDRESS: PERMITNO.
05030299
A Mr PERMIT ISSUE DATE
E;ARC SANITARY QftOL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH O
300 LICENSED CONTRACTOR'S DECLARATION
u I kmby from that I wo licensed under provisions of Clespwr 9(mmmcMing Job Description
IN Sation7")ofDiv an 3 of Ne Bualrwu of ons Coda.end my llronse le
in full fol¢and eRett
uanmCw Lm.« TI--BOARD RM REMODEL
4SDau ARCHr1ECrSDECLARATION n /�,,'1 CONTRACTOR: OPI COMMERCIAL BUILDERS
III l undcnund myplans shell k used a public records `1'ti\�f✓.V"yI
1965 Licensed Professional
ab OWNER-BUILDER DECLARATION
0 I gemma affirm that 11. exempt s an the Genion Co License Lew for tic
O o following moon.(Semon 703 1.5,Business and w.de u.Code:Any city or county
$(L which myuires s pmm11 to ctmnrtm, Blur,impmse,demolish,I,nr repair any structure
poor ement
s,s�^ "Re isucensed c,arm at To Me tic inion nt ofMR,mcgnican'wcense rile a La(Clumaenl -
< Ilwkulkmucdpwmanlwd)ofDivWion3of RBusi esili�unsalawsCode)9 Sq.Ft.Floor Area Val
u�U�a00O
9 Met Imcnc(commencing Screfrom 00 the basis f rOR al ege exams Proarouslon.Myons Code)or
W,k m amps thuefrom and Mw bests for the alleged exemption.My violetlon of
Section 7031.5 by any applicant for a permit subjects the applicant te e civil penalty of APN Number Occupancy Type
not more Nm Bve hundred dollars(5500).
❑Luewnmofthepmpmy.carmyemployeeswkhwg ulkbantecampenu0an. 35720042 . 00
willda Me work.and thes.uctum is natinlended oroRered for Ne(Sec.7044,Business Required Inspections
and Prefanamu Cade:The Can.ecrers License Law does ma apply u an awn.of q P
property w bo builds or im proves themon.and who does such work himseif or through his
own employees.provided that such improvements are notlmaMe t oraRered forsele If,
ha enver,the building or improvement is mid within am your of mmphtion.tic owner-
builder will have the burden of proving that be did set build or Mproro for purpose of
"le.).
/
❑I,Is aw.f of the property,,Business esadd Prnemtlng with:)Thend mmesemrs w
c.nswct the pmkm(Sec.t044, once,ofproperty
rty whoa.Code:)The ConOmrerY and,
came Law does not apply lo ts own.of property who sed pr or cam in Me Calmat,sed,
Wo contracts farauch projects with eeonumur(s)licensees purtwnl w tic ConuactoM1
=PI
aw.
em aemPlmder See .BkPC for this maven
Dau
WORKERS COMPENSATION DECLARATION
1 hereby a(fum under penalty of perjury am of the following decWauons:
have and will maintain a ConiOcou of Co...,w self-insure for Workers Compan- -
I...u provided for by Sation 3700 of 0m Lobar Code.fm Ne Performance of do,
crk for which this Permit is isww r.
❑1 hue and will maintain Workers Compensation Imm ance.as required by Semon
POO of the lAWR Coda,for Nc ppppppeeeeeerfmmmuc,Clubs work fawhich Nis Permit is blued.
My WoteEmpen sulm guYnna Corti and Policy
Carrier. .erA\
CERTIFl
COMPENSATION INSURANCE
RKERS' S_
(Thusadm mend not becomplemd if Mw permit is foram hundred dollars(SI00)
or ke4)
1 cattily that in the performance of the work for which this permit is issued.I shall not
employ any person In any manner an as To became subject to OR Workers'Compensation
Laws of Cnifomh.Dem
Applicant
NOTICE TO APPLICANT:If.after Ranking this Cedificau of Exemption,you should
became subject To the Worked Compensation provisions of Me Labor Cade,you man
.J O forthwith comply with such provisions or This permit shall be deemed mmkcd.
'Z
, a y CONSTRUCTION LENDING AGENCY
(r I kroby0firm Nal them is A cuWcunn 1C.OnS.Semy to,the pcffurrome.f
a> Mw work for which this Permit is issued(Sm.309'1,Civ.C.)
4 Q Lenders Name
7 z Lender's Md.
fJ/Q 1 certify that I have reed this application am slow the,taw above Information is
fy E mrrtct.I agree m comply with W city and empty mdlunaa and sum IS"relating To
0 building convection,and hereby mNmine mpresenutives of This city TO enter upon the
W a1nove-men0oned property for inspection puryose4
(We)agree w ave,indemnify and kap Mmtleu tic City of Cupertim against
y Iimilida,Judgments.costs and expenses which may in my wry acerin against mid City
(„) in comae cme of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOI Issued by: Date
SOURCE REGULATIO
Re-roofs
Signature of App e nyanmr Uate
Albls HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or run=Wilding mcupanlswre m handle hazardous material
de0ncd by Mw Cupertino Municipal Code,Chapter 9.13,soul Mw Health and Safety
Semon 35533(3)+ All roofs shall be inspected prior to any roofing material being installed.
❑Y.
Will the applicant car r r/trevereo building aaupant um equipment or devices which If a toot is installed without first obtaining an inspection,I agree to remove
hmarmus air contaminants u dcMed by IN Bay Area Air Quality Management all new materials for inspection.
nT
❑Ya
1 heves ren Mw hvardmsmawriW rcquimmmu seder Chepwr6.95 ofMw Califor•
Idm
ealth@S rty Cade,Sari..35505,35533 end 35534.IwAcrewal On fuse Wilding
not curre.ly hero a wnant,Nu it u my responsibility m notify taw occupant of Ne
re be me priorwiuuancc ofaccrMrnwatOca Signature of Applicant Date
ownar.fm,hari,a�desant� Dam All roof coverings to be Class"B"or better
PERPAIT � OPEIJ" UPDATE QUERY CQIJPdT I REPORT + PRIMT I SpfiPLE I, Y.OPY I' RLE I EXIT , i 0K
Ilpdal:e an exi.stinq permit record ( Conlmbc
Lookup...
'ERNIT NO 05030299� STATUS ICiCLOSED APPLY DATE 03/30/2005;OPER conniew !, Notepad
MASTER NO F —INOTES 0, PERMIT ISSUED 03/30/2005';OPER
W
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PROJECT CERT ISSUED 07/18/2005� OPER- Cancel
PROJ DESC CERT NUMBER i TYPE ;
- __— -__ J' _ J - - - � - - Field Code D...
CAS 95014==-
RPN , 35720042 00 �IUPDATE ADDRESS 1",�
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PRBC RDDR 5 RESULTS I1RY 1C/S/2 CUPERT[NO
� - -- ---- i Sort By Col 3
OWNERi ARC SIGHT IiOWNER2 F
-
-- -- _. --� _ _- _. - .J �_-___� Sod By Col 4
0 RDDR _ �C/S/2 CUPERTINO CA CR 95014
-- _---- -_ -- - ---_-- . -_ ._ ._ - , View Object
Geo'Link
PERMIT TYPE COMML-TIS, US.0-404 TYPE 437 _ �� ENRGY CODE) q
uit
USAGE CLASS O U N_R _ �i PERMIT FORk1 APPLICATI,] TANII/SEWERI
APPLIED UALUATIONI 00 APPRUD BY:
CAI_C UALHATIO141 _J- 600) ,,.21312]) ,OWNER.PHO ( 408244.5 0 ss,
OWNERSHIP I111PRIDATE JNOTES (Y/N/D) rl cONTR PH0
SPECIAL CONDITIONS/NOTES JESCR01! —J
TI--BOARD RM REMODEL VERIFIED
CONTRACTOR: OPI COMMERCIAL BUILDERS JIFTUE LOCTRtif ,
STILL NEED JB PAINTING BL 5/23/05
i
TATUS <O>pen, CC>losed-,-<U>oid, <H>old_,_<R>eject, <E>xpired __�__.
PERMTT_S- _ --_ -
•
Gty of Cupertino
• 10300 Torte Ave.
Cuper0no,CA 95014
Fax ,
To: r JC K L I _ From:( C L. O C GGA lip
Fam -�2 J� — 9 � Date:
Phone: Phone: Y09 77-7 -3-203
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