08010047BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19480 STEVENS CREEK BLVD
OWNER'S NAME'
ARC HrrECr/ENGINEF7t:
PERMIT NO.
08010047
FERMIT L-GUE DATE
01/09/2006
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o 0 LICENSED CONTRACTOR'S DECLARATION
�, Job Description
1 ltcroby affirm that 1 am litratacd under provisions of Chapter 9 (commcncing p
i will. Section 7000) of Division 3 of the Hnrs;nrss and Professions Code, and my ianw is j RM EX STNG MONMNT CABNT INTL NEW I LLT ' D MON CBNT
y in full come and effT_V " .1 3
license Gass USNG EXSTNG BASE ( NON- STRCTRL )
� ?
F ❑ Date Contractor
f a J ARCHITECTS DECLARATION
I understand my plats shall be ash -s pu�iecords
yU
O � Licensed Professional
01 OWNER -BUILDER DECLARATION
j < M 1 berohy affirm that I am exempt from the Contractor's License Law for the
:0 00following reason. (Section 70313es , 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 file a signed statement
= 0 that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Sq .
F- (commencing with Section 70D0) of Dfvision 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (S-500). 37501014.
❑ L as owner of the property, or my employees with wages as their sole compensadon,
will do the work, and the structure Is not intended or offered for sale (Sc_ 7044, Business
and Professions Code: The Contactors License Law does not apply to an owner of
property who builds or improves thereon, and who dues such wort himself or through his
own employees, provided that such improvements are not intended or offered for sale. 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.),
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contacts for such pmjects with a contractm(s) licensed pursuant to Lite Contractors
License Law.
❑ I ore exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARA7ION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the petformanox of the
work for which this permit is issued_
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Wo s
1 S-D6 '35 (/ 6
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is for one hundred dollars (S 100)
Of less)
t certify that in the performance of the work for which this permit is issued. 1 shall not
employ arty person in any manner so as to become subject to the Women' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
7 z forthwith comply with such previsions or this p=n.it shall be deemed revoked.
7
;4 CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a contortion lending agency for the performance of
4 > the work for which this permit is issued (Sec. 3097, C(v. C.)
4 Q Lender's Name
z Lcndees Address
Q I certify that 1 have read this application and state that the above information is
L H correct 1 agree to comply with all city and counry ordinances and state laws relating to
D U building construction, and hereby authorim representatives of this city to enter upon the
W ahovc-mentioecd property for inspection purposes.
y LL (We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, coats and expenses which may in any way accrue against said City
,z in consequence of the granting of this permit.
'--" APPLICANT UNDERSTANDS AND
AN,D WILL CO LY WITH ALL Nn POINT
SOURCE REG lON'
Applicant/Contactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mum ■I Code- Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑ Yes
Will the applicant or future (ding occupant use equipment or devices which
emit hazardous air tuntnminants defined by the Bay Arta Air Quality Management
District]
C] Yes No
1 have read the hazardous materials requirements under Chapter 6.95 or the Califor-
nia Health & Safety Code, Sections 255 5., 25533 and 255 understand that if tic building
does not currently tmW a rrnaotha
t at it is my respR - to notify the rocker t of the
rcquimmcn{a whic oast _icatc o up
9L C
Date '
Issued by:
Re -roofs
Type of Roof
Floor Area
$9500
Required Inspections
Type
Date — ?: hi -
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 otApplicant Date
All roof coverings to be Class "B" or better
Owner or authorized