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Bu1L.pIy,Q.ppl�j 18RANGE AVE BSMNT BLDG B TBD - TO BE DETERMINED 08030162
OWNER'S NAME.'
PERMIT ISSUE DATE
MARCI PROPERTIES LLC 09/05/20.08
PHONE: SANrrARY NO. CONTROL NO.
ARCHIECTIENGINEER: I I I BURRING PERMITINFo
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I w licensed under provisions of Chapter 9 (commancing
with Section 70D0) of Division 3 of the Business and Professions Code, snd my license is
in full force and effect_
License Class Lac. N
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licersed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contactors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to irk a signed statement
[hat he is licensed pursuant to the provisions of the Contractors Utznse Law (Chapter 9
(commenting with Sccllon 7000) of Division 3 of the Business and Professions Code) or
chat he Is CX=pt therefrom and the basis for the alleged cwoption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars (S500).
❑ 1, as owner of the property, or my amployeea with wages u their sole compensation,
will do the wort_ sod the structure is not intended or offered for sale (Sec. 70", Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himse f or through his
own employers, provided that such improvements ate not intended or offered for sale. If,
however. the building or impnovemrnt Is sold within one yew of completion, site owner -
builder will have the burden of proving that he did am bdW or Improve for purpose of
L u owner of the property. am exclusively contacting with licensed contractors to
onsuuct the project (Sec. 7044. Buahcas and Profcaxiom Code:) The Conawtes U.
cense Law does not apply to an owner of property who builds or improves thereon. and
who contacts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
0 1 awtZynpt un Sec . B sit P C for
Own IY "� Date rJ
WORKER'S C OMPENSAT-ION DECLARATION
1 hereby ainna ender penalty or perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compan-
sation, as provided for by Section 3700 of the Labor Code, for the performance: of the
work for which this permit is issued.
Q 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number me:
Carrier. Policy No:
CERTIFICATE OF IXEMPTTON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
or Iess)
I ca tify that in the performance of the work for which this permit is issued. 1 shell not
employ any person in any man o subject to the Worl¢rs' Compensallon
Laws of C la. Date
Applicant 4
NOTICE CANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shalt be deemed revakrd.
CONSTRUCTION LENDING AGENCY
1 hereby allErm that there is a comtniction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ, C.)
,Lenders Name
Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordim aces and state laws relating to
building construction, and hereby authorize repr sentatives of this city to enter upon the
above-mcntionad property for inspection parposes_
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expanses which may In anyway seen against said City
isfhmNoegaingoPerm
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SQIIA5E REGUI,4qlGKS.
rL�C_l �r Ci
Srgnatuic of Appliant4enallilbr
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or har d)e hazardous material
as damned by the Cupertino Municipal Code, Chapter 9.IZ and the Health and Safety
Cork, Section 25532(a)7
El Yes No
Will the applicant or future building occupant use equipmeol or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
[I Yes Q6n
- Job Description
408.4' BASEMENT COMMERCIAL SPACE IN MIXED USE
BUILDING. BLDG B
Sq. Ft. Floor Area $53170 Valuation
35717058.
Re -roofs
Type of Roof
Occupancy Type
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.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcal[h & Safety Code, Smions 25505, 25533 Bnd 25534.1 underaand that irsire building
does not cunendy have a tenant, that It is my responsibility to notify the occupant of the
rc jp�s which must bolrjbl prior to issuance of a Certificate of occupancy.
or authorizcd agent
Signature of Applicant Date
All roof coverings to be Class In' or better