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BUILDING DIVISION PERMITCON"t'RA4'TaUI2y;�'^"^
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BUILDING ADDRESS:
PERMIT "03100207
-$SOC
R'S NAME:
PERMIT ISSUE DATE
M
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
7_1
LICENSED CONTRACTOR'S DECLARATION
Jb Description
o
f Chapter 9 (coencin
pm ons omm
I hereby affirm Nat 1 am licensed under ud g
.IMS tion IX )of Divisioa3ofde Businusand Professions Codeandmyliccnwis
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TENANT IMPROVEMENT r aY«e
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ARCHITEC.,S DECI.A N
CONTRACTOR: R-3 BUILDERS (03/02/04
JUN 24 2004
1 undersssnd my plans shall he used aspub] records
BUILDING
Licensed Pro@ssimml
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Commater'a License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a Permit in construct. alter, Improve, demolish, or repair any structure
prior to its issuance. also requires the applicant forsuch permit to rile a signed statement
that he is licensed pursuant to the provisions of ate Comments License Law (Chapter 9
Sq.Ft.Floor Area
1'
Vav�t*"816
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
Met he Is exempt Nerefmm and de basin for the alleged exemption. My violation of
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any applicant fm a permit subjects the applicant to a civil penalty of
.1 mom than five hundred mllms ($500).
35908018.00
01, as owner of the property. or my employees with wages as dons sale compensation,
will do Ne work, end Ne swan n isnot intended or offered for ale (Sec. 7044, Business
Required Inspections
and Professions Cade: The Commumors Line Law does net apply an an owner of
property who builds or improves thereon, end who does such week himsel f ar through his
own employees. provided thalauch improvements an automated oroRered forsals. IL
however, the building or improvement is sold within ane year of completion. the owner.
builder will have Use burden of proving thin W did arm build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licenxd canuacmrc to
come= the projem (Sec. 7W4. Business and Professions Cade:) The Canuactor's L].
conse law does not apply to an owner of property who builds or improves Braman. and
who contracts for such projects with a conwctar(s) licensed pursuant o the Contnmars
Llceare Law
❑ I ten attenuunder Sec. , B B P C for this mason
Dae
WORKER'S COMPENSATION DECLARATION
1 hereby affi nl under penalty of perjury one of Ne following declaration:
1 have end will maintain is Certificate of Consent m sel6lmure for Worker's Compen-
sation, as provided for by Section 37W of de labor Code, far the perfonnanm of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Iawo ncc, m required by Section
"" of the labor Code. for Ne perfannumm of the work for which this permit is issued.
My Worker's Compensation Insunme carrier and Policy r beram:
Cartier. 5W'T ¢- i u Nva lu'-y No.: �8
/ CERTIFICATE OFEXEMPfION FRO SKIERS'
�J- COMPENSATION INSURANCE
(Thu semion need net becompteted if the permit is fnronehundreddollars ($107)
or Mss.)
1 certify 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 becomesubject to the Workers'Compema0an
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject m Bre Worker's Compensation provisions of the labor Code, you must
forthwith comply with such Poevisiam or this Permit shall M deemed modem.
CONSTRUCTION LENDING AGENCY
I hereby effort Nat there is a comuuction tending agency for the pefformance of
"
Me work for which this permit is issued (Sec. 3097, Ci, C.)
Lenders Name
Lender's Addm,s
1 modfy that 1 have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and sum laws relating In
building conatrunian, and hereby authon. mpmsenutives of this city to ants, upon on
ahove-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
I]abi]ides,judgments, casts and expenses which may in anyway acerae against said C]ty
in copse of the Starting of this permit.
APPLI ANT N STANDS AND WILL COMPLY WITH ALL N -POINT
Issued by: Date
SOUR R UL N
10 `
Re -roofs
Type of Roof
of App]immuContnmor Dae
HAZARDOUS MATEWALS DISCLOSURE
Will the appl]cam or future Wilding occurrent store rehandle havardous interval
reined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
c, Some.
All roofs shall be inspected to any roofing material being installed.
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prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use cyuipmwt or devices which
mit Woodous air contaminants is dcfrned by Bre Bay Arca Air Quality Man.gcmcm
all new materials for inspection.
Disaict'1
❑Yes EM
theharaNnusmatefialsmquimmenmundcrChapter6.95oftheCalifoe
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Signature of Applicant Date
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All roof coverings to be Class "B" or better (/
caner ser authors, d reg rat me