08070123CY OF CUPERTINO
BUILDING DIVISION PERMIT
J?;
BUILDING DRESS: - PERMIT NO.
10 50 DE ANZA BLVD CRAFTSMENS GUILD INC 08070123
OWNER'S NAME. PERMIT ISSUE DATE
ATLANTIC REFINING CO 10566 S DE ANZA BLVD 07/18/2008
PRONE - SANITARY NO. CONTROL NO_
(408)366-1000
ARcwlF.crfENGB'fEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACPDR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7009) of Division 3 of the Business and Professors Code, and my license is
in fd1 force and elf p
L.Icenso Class Lie..
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans sball be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aflum that I am exempt from the Contractors Llcensa Law for the
following reason. (Section 70313, Business and Professions Coda•. Any city or county
which requires a permit to construct, alter. improve. demolish, or repair any stmesme
prior to Is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed purswnt to the provisions of the Conuactor's Licema Law (Chapter 9
(commencing with Section 70DM of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the bads for tha alleged exemption. Any violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollar (S500).
❑ L as owner of the property, or my employees with wages as their sole cmnpeasation.
will do the wort. and the structure is not intended or offered for sale (Sec.7044. Business
and Pmfesdens Code: The Contractors License Law dos not apply to an owner of
property who builds or Impmxvrs thereon. and who does such work himself or through his
own omaploycm provided that such Improvemenu are not Intended or offered for sale. IL
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 purptse of
tale.).
❑ L as owner of the property, am exclusively contracting with lk= ual contractors to
consumes the project (Sec 7044. Business and Professions Cade.) The Conummes Li-
cense Law dos not apply to an owner of property, who builds or Improves themmr. and.
who contracts for such pr*= with ■ contracfar(s) Licensed pmauant to the Contractors
LCcemae Law. -
❑ I am exempt under Sec . B h P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration
❑ 1 have and will maintain a CertiLam of Co sent to self -Insure for Workers Compen-
satim at provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Irtunnct. as required by Section
3700 of the Labor Code. for the performance of the work for which this permit is Issued.
My Worker's Compensation insurance ' and Policy (Min am:
Carter: LJ��iIL tlyf Policy No.: 0 4
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
('This sccdmr need not be completed If the permit is for one hundred dollars (S 100)
or less)
I ccrtif that in the performance of the work for which this permit is issued. I shall not
employ any person in any mmmcr so as to became subject to the Workers' Compensation
Laws of California_ Data
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
became subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby drum that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec 3097. Civ. C.)
Lratic s Name
Lenders Address
I certify that 1 hark read this application and stun that the above Information
00trecL I agree to comply with all City and county ordinances and stale lawn relating to
building construction. and hereby utWarre representatives of this city to enter upon the
above-meatitned property for inspection purPOSrL
(We) agree to save. Indemnify and keep harmless the City of Cupe mo agalml
Wbilitlea,judgmenbs. coats and expanses which may In any way ague against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND NON -POINT
SOURCE REGULATION
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will tin applicant or future building occupml roe or handle hrurdom material
as dented by the Cupertino Munllci .Code. Chapter 9. It and the Health and Safety
Code. Section 25532(a)? /
❑ Ycs 0 No
Will the applicant or fuh..... bull g samupant use equipment or devices which
emit haardona air contsmhnants u hncd by the Bay Area Air Quality Management
District?
❑ Yea 6WNo
1 have mad the hazardous materials requirements sander Quper 695 of the Csllfur-
nia health h Safety Code. Sml"u 25505.25533 and 25534. l w&mand IMt ifthc boulding
does not cunenity hue a saran a is my responsibility to notify the ecergant of the
requiremens which mats s. met pri issuance of a Certificate of Occupancy.
Owner or wthoircd agent _-- Date . .
Job Description
COMML TI RLOCT BTHRM ELECTRCL STRG AREA & ADD NEW
EXIT DR
Sq. Ft. Floor Area $15000 Valuation
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class'W or better