03090032v\
W
4
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMAT30N!,
-
n3, o'4
oUILDING ADDRESS:
SCOTT ARCHITECTURAL GRAPHI
gMITN003090032
0400 STEVENS
ER'SNAME:
1275 N. DUTTON AVE. #4
PERMIT ISSUE DATE
CUPERTINO CITY CENTER ASSOC
10/27/2003
NE:
(707) 545-4519
SANITARY NO, CONTROL NO,
ARCHITECI'IENOINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH-
0 0 0 0
LICENSED CONTRACTORS DECLARATION
Job Description
I affirm Nat i am etl under provisions orChapterC.dA,r 9 (commencing
p
ion 7
with 5coion]g1B)of Divisian3of Ne Busincas end Professions Cotic. endm license is
fro.
LMA jlf��' GN�DyZ
SIGNS �,�ee
Claentle
os¢nee Class
C.mmcu.r_�$_
EXCLUDES EMA MONUMENT SIGAPJAL�®
is tCHITECPS DECLARATION
I understand my plans shall be used as public records
MAY 1 2��¢
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby License Law the
affirm that 11. exempt from the Cocoons
fallowing rcasoa (Section ]1131.5, Business and Co
Maso Professions Code: Any city or county
Co :
BUILDING
which requires permit ve de
construct, alley, improve, or repair any swment
priorm itsissuance.also Acquires the for suchpetoia file ssigned nammem
n Ac h AcrAiL t
that nlicensed the") previsions LicenseLaw (Chapmr9
Sq. FL Floor Area
Valu ti�fi000
cingwitpSectio 7to
(commencing
(commencing with Section7")Add of Division 3 of the Businesa and Prafessinna Cnde) ser
an is therefrom and Ne burs for the alleged uempn t Any= of
Section, by any Applicant for aPermit subjects the applicant to acivil penalty of
31.5 b to
er00
Occupancy Type
than
not more than Rva handrail (roma (&sore.
❑ LesOWner or the property, or my employees with wages u their said ema, Ation,
will do the work. and the svueture is not intended or offered for sale (Sec. 7094, Business
and Professions Cade: The C.romemrs License Law does oat apply to an owner or
Required Inspections
property who builds or improves thereon, and who does such work himself or through his
own employees, provided Bud such improvements are not intended oroffc.d for Ale. If.
however, the building or improvement is sold within one year of completion. the owner,
builder will have the burden Of proving that he did not build or improve for purpose of
sale.).
,
❑ 1, as owner of the property, am exclusively contracting with licensed convectors to
construct she project (Sec. 7004, Business and Professions Cod,:)no Contractor's Li.
cense Law does not apply in an owner of property who builds or improves demon, and
who contacts for such projects with a wrare ctor(s) licensed pursuant to the Contractors
License Law.
❑ I ane exempt under Sec. , B is P C for this moon
or Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declansions:
have and will maintain a Certificate of Conant to self -insure for Workers Compcn-
n, u provided for by Section 3]00 of the Labor Code, for the performance of she
1c,
`
for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as required by Section
of the Labor Code, for the performance of the work for which this pamril is issued.
Workers CnmpenAfton ensu neecartiers�errd Policynumhera •x/70artier. �kL9n . -♦"ra yr�icy No.: f Ov+O
CFRTIFIrliTE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted if the permit is forenc hundred dollars (g If10)
or lass)
1 eenify that in the performance of the work for which this permit is issued, I shall nut
employ any person in any manner so as to become subject o the Workers' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Cenificam of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you must
ronhwhin comply with such pfovWnna or this Permit shall M deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this pnmit is issued (Sec. 3097. Civ. C.)
Lender's Name
_
Isnder's Address
1 eenify tat 1 have read this application and &Asia that the Above Ofum i ion is
'
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorim representatives Of this city to enter upon the
pe purposes.
shove-meminned pmperst fond
(We,) agree to Ave, indemnify and keep harmleas the City of Cupertino against
a
liabilidu,judgments, e gaming eapenAsrait. may in anyway accrue against said City
expense,
inconsequence9 fthe granting of this permit.
APPLICA� DS AND WILL COMPLY WITH ALL NONPOINT
Issued by: Date (//I
SOURCER S. /O/`'�
Re -roofs
Signem aAPPliuO DataHAZARD
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII theapplicant serfuture building e, nomor handle
s 'armed by the COpanino Mu icipel Cada Chapter 9.13, and the Health and Safety
Chapt Health and Sated
-
.Semen zss32(ap
❑Yes AN.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I to
Will the applicant er future building occupant use aquiliment or devices which
agree remove
II ha,Amaas it cut, an v dcrim d by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑Yes
I have, mad the havaNnus materials requirements under Chap er6.95 of the Califon
ma HealthffiS cry Code cdons 25505,8533 and 25534.1 undearnd thmifthe budding
does nos cu a the it k my responsibility m noalj the rceup t of Nc
mquirem!0 i a e I,Y.aAaen enificam Q pane
late
Signature of Applicant Date
All roof coverings to be Class "B" or better
owner authooOa ant