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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
�,�NTRAGTCIRIN.ORMATION;
BUILDING ADDRESS:
PORTFOLIO REALTY MANAGEMEI
F fMITND'06060260
21666 STEVENS CREEK RLIZD
OWNER'S NAME:
PERMIT ISSUE DATE
Nk PORTFOLIO REALTY MANAGEMEN
NE:
SANITARY NO. CONTROL NO,
ARCHrTCffENGINEER:
BUILDING PERMIT INFO
_
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hcmhy affirm Nat 1 am licensed under provisions of Chapter 9 (Commencing
with Section 70(10) of Division 3 ofthe Business and limfca;ues Code.sM my Hearst is
in full romeamdirect.
TI BUSINESS SPACE EXTENSION ELECTRICAL ONLY
Under. Class Lic. N
Dam Camnchr
ARCHITECTS DECLARATION
I understand my ithmashall be reed as public retards
BASSO ELECTRIC COMPANY
Licensed Pro(esaihnol
OWNER -BUILDER DECLARATION
li
I hcmhy atTM that I am exempt from the Canmmmrs Llecnm Law (a, the
following rctson. (Section 7031.5, Bunncst and Pmfetians Codc: Any city or County
which requires a Permit to construct, alter, improve, demolish, or repair my stannum
! prior to da issuance. also requires thin applicart for such permit w fill a signed rade
he is licensed We of the Coeuacmrs Unchad Law(Chapor9
Sq. Ft. Floor Area
Valuation
Chat purswnuo provisions
(commencing wish Section 700(y) of Division 3 of the Business and Professions Child) at
.
$5180
shat he is exempt therefrom and We basis for the alleged dmmptio o Any violation of
APN Number Occupancy Type
P y Yp
Section 7031.5 by any applicant far a permit subjects We applicant m o civil penalty of
not more Nan five hundred dollars(M),
I, as owner of the property. or my wploym wish wages as their sole compensation,
win de the work- ad the.... is Out intended or offered for side (Sec.]oa4, ausixss
Required Inspections
and Professions Cade: The Contractor's License saw does not apply W an owner of
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property who builds or improv Hereon, and who doessuch an rkhimselfor though his
awn employers, provided dot each imp orwavess are out intended aroffered fm ale. If,
however, We building or improvement is mid within one year of compichaa. We owner.
builder will hoe the bmdcn of proving that he did not build or improve for purpose of
sold.).
I, as owner of We progeny, am ucluiively conuec,ing with licensed commucmrs to
constroct she project (Sec. 7014. Business and Prufcssime; Code:) The Comu.eors V.
cense taw does not apply to an owner of property who builds or improves Winton. and
who contracts for such projects with a conuacmr(s) licensed Partner to We Contractor's
License law.
El I am exempt under S"ec' , B & P C for this revan
, �Lti �
Owner
�r'�-e''")—`-f
• wORRG(. COMPENSA ONI� DECLARATION
1 hereby af0on under penalty of perjury ane of the following declarations:
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1 hire and will malnu;o a Cerditate of Content m self-imunt fm W0&ers Campen-
-
sation, u provided for by Section 3700 of We labor Code, for We performance of the
wrork for which this permh is issued.
❑ 1 have and will maintain Workcls Compensation Insurance, as required by Section
3700 of IM Labs Code, for We pert.... of the work for which this permit is;ssued.
My Workers Cnmperuail I. tuner and Polity number art:
Caoier. Policy No.:
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rl'huseclim, need.., be complcmd if We pcmot is fmonc hundred dollars (SIM)
or less)
1 certify that in We performance of We work for which this permit is issued. I shall not
employ any parson in my M=mrz nbS4oTe object to We Workers Compensation
/Cr''
laws of Glifomia.��,.
..�3
Appliant
NOTICE TO APP (CANT: If, aMr making this CeniOcam of Exemption, you Would
Woman subject W We Workers Cmnpewdon previsions of We sabw Code, you most
forthwith comply with such Pmvisimu or this Permit shall be deemed invoked.
CONSTRUCTION LENDINGAGENCY
I hereby aRmm Wt Were is a Commandant lending agency fm We Performance of
!
dm work fur which this pestes, u named (Sec. 3097, Civ, C)
(Sed,
Undoes Name
lenders Address
•
I certify that 1 have read this application add rete dad the above information is
COMM 12g= in comply with all city and county ordinances and state laws relating to
building Construction, and M1crehy authorim opresemarives of this city to enter upon the
above-mcmioncd property for inspectioner
purow;cwhich
(We) agree m save, indemnify and keep harmless We City of Copenlno against
ms.
nds. es
shooting eapcnmsmit. may in any waya<cmc againa said City
inconsequece of the
inconsequence of We shooting of she terms,.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Issued by: Date
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Re -roofs
Sega an: of A� ppi Dow
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof. .
Will the applicant or future building occupant start in handle hasaNeus material
as &fmcd by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety
Cadc, Section 25532(a)7 ,
❑Yu No
All roofs shall be inspected prior to any roofing material being installed.
Will We applicant or (umrc building accupam use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
cath havarems air conuminanu as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District' ,x�
❑Yes g�N.
1 have read We hvarnes materials rcquidemenu umkr Chaper6.95 of sac Cdl;f.r
ria Health & Safety Cods, Sections 25505.25533 and 35534.1 undersand thxtifthc building
does not currently ham a moms wt it u my respowbiliry in notify We aceup sat or We
requi tawhle"hmtweeme1pr;arm; aameof. Certificate ofaroparey.
Signature of Applicant Date
co
roof All verin s to be Class "B" or better
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Owner or amhoriud agentDam '