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CITY OF CUPEK111
BUILDING DIVISION
BUILDINeDRESSTEVE
PERMIT
CREEK BLVD I SAN JOSE CONSTRUCTION
OWNER'S NAME:
EVERSHINE VI LP
ARCHITECTIENGiNEER:
LICENSED CONTRACIUK2i UrIULARAI tun
I hereby affirm that I am licensed under provisions or Chapter 9 (commencing
with SectionecD ion 3 of the Business and Professions �o anted my license is
n full farce andnd of effect.
:dcense Clas Lic. #
Jam ContraMar
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's 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, dcmullsh, or repair any structure
prior to its issuance, also requires the applicant far such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
(commencing with Section 7000) of Division 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 five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work 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 or
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
cense Law docs not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for worker's compen-
sation, as 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 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 War s Compens 'an Insuragce carrier and Policy number 67
Carrier. q N iN t Policy No.; 2J
CERTIFICATE OF E7 EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lendees Address
1 certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
ab ov cru ed property4b inspection purposes
(Wc) a e to sc&e indymnify and keep harmless the City of Cupertino against
Iia ilities,judg cobs, sts and iJ}pergo which may in anyway accrue againstisaid City
COMPLY WITH
HAZARDOUS MATERIALS DISCLOSURE
ill the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑Yes C] No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
Q.q
-ad v ousmatcdalsmquimmemsunder Chapter 6.95ofthc lifor-
ety ode, Sc dons 25M5..
05, 25533 and 25534.IunderstandthatiCthc wilding
n y ha a tic atitish h t l prior to issuance of a Certificate d(c up �I
Owner r uthorizc agent J pt Da�mV
1210 COLEMAN AVE
(408)986-8711
PERMIT NO.
08030043
PERMIT ISSUE DATE
03/24/2008
SANITARY NO. CONTROL NO.
BUILDING PERMITINFO
Job Description
REVISE ONSITE UNDRGRND STORM/SEWER LINE—ORIG
PERMIT #07060128 NO NEW PERMIT.
Ft. Floor Area
36906010AN
Issued by:
Re -roofs
Type of Roof
$0
Required Inspections
Type
Date2�-�
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 or better