03080083 (4) CITY OF CUPERTINO
BUILDING DIVISION PERMIT �ICONTRAC-,TORANFORMATION i` ,
BUILDING ADDRESS: ARTS I GNS PERMIT N2.3 0 8 0 0 8 3
'
BE NAME: 1615 SAN`�_L'AZARO AVE - PERM1715SUUUEDATE
CAAREN I 08/18/2003
NE: (408) 24.x'-7133 SANITARY NO, CONTROL NO.
a� y
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
?00 LICENSED CONTRACTOR'S DECLARATION i
wa I hereby affirm that 1 em limned under proyiiions of Chapter 9(commencing y�Job Descri tion
<�
with Section 7gkl)of Division Jof the Business and Professions Code.and my license is � (/
imm� err
r e n L{Q(Q
$'�i License C 45 Lie.a� SIGN
DV1
canlu�$$ay/
£q ARCHITECTS pBBL/rRAT10N /
22d I underslanJ my plana shallMuud llS puMie recnNa `
560
Licensed Pmfcssionaf
,5 OWNER-BUILDER DECLARATION
2 1 hereby affirm that 1 am exempt from Use Contractor's License Lew for the
Mfollowing reason.(Section 703 1.3,Busimeas and Professions Cade:Any city or county
which requires a permit in construct,alter,improve,demolish,or repair any structure $7175 5
_iy poor In its issuance,also requires the applicant for such permit to file a signed statement
q � thatheisliccnwdporsuantwtheprovisionsoftheContracor'sLocatefaw(Chapter9 Sq.Ft. Floor Area Valuation
z$❑ (commencing with Section 7")of Division J of the Business and Professions Code)at
3
that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of 35717012 . 00
Section 703 l.5 by any applicant for afarads subjects meapplicant toacivil penalty of APNNumber Occupancy
not more than fiw hundred dmane lau(M). P y Type
❑1,as owner or the property,or my employcec with wages an;their sate compenution,
will do the work and the grcture isnot intended or offered moafe(Sec.70th,Business lul —
and Professions Code:The Contractor's License Law docs not apply to an owner or 103 — UFER d Inspections
property who builds or improves theuon,and whodaes such work himselfor through his
owncmployees,provided Wreath Improvements are not intended OroRered for nk.If. 104 — REBAR
however,the building or improvement is sold within one year of completion,she owatn
builder will have the burden of proving that he did not build or Improve for purpose of 105 — ANCHOR BOLTS
"le')' 304 — ROUGH ELECTRICAL
❑1.as owner of she property,am exclusively contracting with licensed contractors to
construct the p1Oject(Sec.70de,Business and Professions Cade:)The Contractor's U. 505 — FINAL ELECTRICAL
cane law data not pply to an owner of property who Index or improves shaman.and. 514 — FINAL PUBLIC WORKS
who contracts for such prejecu with a contractor(&)liccnud pursuant to the Conmewfa
License Law.
❑ l mo exempt under Sm. B h P C far Nls reason
r Dow
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under fatally or perjury one of the following declarations:
1 his
roil will meinuin•CeniRcak of Cansenl m ulfinsum for Workeh Compere
scion,u providetl for by Section 7700 or the labor Code.for the performance or the
work for which this permit is issued.
❑1 basic and will maintain Worker's Competallon Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Worke—�r'a�s ComnyPreematjppinsumwe carticr an o'cy nu Mau:Lf 11L(,�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not McomplekJ ifthe Permit is patina hundred dollars P$100)
or less.)
I comfy that in the performance of she work for which this Permit is issued.I shall nm
employ any person In any manner u as in become subject to the Workeri Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenificare of Exemption,you should
become subject to the Worker's Confrontation provisions of the Lahm Code,you mug
7 z forthwith comply with such provision.or this permiuhdl Ise deemed Invoked.
OCONSTRUCTION LENDING AGENCY
I hereby affirm WI Nem is a construction lending agency tar the pmfarmance of
Y, Ne work for which this permit is issued(Sec.3097.Civ.C.)
1 A LcnJcr;Name �v —
Z)z Under;Address
..7 p 1 cattily that 1 have mad this.pplicidm and ante that the shove Information la
cortect.I agree to comply with all city and county ordinances and cele laws mining to
0U building construction,and hereby authorize representatives of this city to enter upon the
4 anava-mentioned property for inspection purposes.
ti csju agree s.sew,indemnify and keep may
roan dm City of Cupertino id sty /'1
r7et incofiabimishipudg,oftheosuandupevesmiichmayinenywayacruegaingmidCity
Uw7 in conuqucnec of the graining of this permit.
A T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S REGULATI
Y Re-roofs
Signgurcor AppljcanthContdgetmr Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupanl gore or handle bavudous material
u dcrined by the Cupenino Municipal Code.Chapter 9.11,and the Health and Safety
O."'Imundous
Section 35531(,)? 91, All roofs shall be inspected prior to any roofing material being installed.
�YcsWill the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
air conNminents as defined by the Bay Arca Air Quality Management all new materials for inspection.
District? --//
❑Yes Z14
1 have real Ne hevardom makriab mquimmenu under Chapkr6.95 orthe Califo,
no Safety CusceSecvmu25505.25333an.12553a.l understood touristic building
nos c ally haw a tenant.that is is my responsibility to n rd I the oaeupant of the
rcquirem hichmust met poor at issuance ofaOcrlificas,ofOccup �fr �SignatureofApplicant Date
!�
ncr Lir authorised agent 1 All roof coverings to be Class "B"or better