06080011CITY OF CUPERTINO
BUILDING DIVISION PET I
BUILDING ADDRESS:
10100 N TANTAU.AVE
OWNER'S NAME:
SAND HILL PROPERTY
PHONE:
ARCHITECT/ENGINEER:
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1 hereby affirm that 1 am licensed Ender provisions of Chapter 9 (commencing
+ith Section 7000) of Division 3 of the Business and Professions Codc, and my license is
s full force and effect
;ateasa Lic. p �
)etc - Cogqtractor
ARCH ITECTSI DECLARATION
1 understand my plans shall be used as public records
Jecnsed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt) from the Contractors License Law for the
ollowing reason. (Section 7031.5, Business and Professions Code: Any city or county
vhich requires a permit to construct, alter, improve, demolish, or repair any structure
)rior to its issuance. also requires the applicant for such permit to file a signed statement
hat he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
commencing with Section 7000) of Division 3 of the Business and Professions Code) or
hat he is exempt therefrom and the basis for the alleged exemption. Any violation of
iection 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
tot more than five hundred dollars ($500).
] 1, as owner of the property, or my employees with wages as thew sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Code: The Contractors icense Law does not apply to an owner of
property who builds or improves thereon, Ld who does such work himself or through his
own employers, provided that such improvements are not intended or offered for We. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70", Business and Professions Code:) The Contractors L-
eone Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a coplractor(s) licensed pursuant to the Contractors
License Law,
O lam exempt under Sec B & P C for this reason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 hereby aff rm under penalty of 1,erjury one of the followings declarations:
I
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's 4nipensation Insurance, as tcquired by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Corn aation I�gurance carrier and Policy number arc:
Cartier: Policy No.: Z5:�/_��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be complcled if the permit is for one hundred dollars ($I00)
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 been sulyect to the Workers' Compensation
_ Laws of California. Date 7 It '[3
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become 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.
CONSTRUCTIQN LENDING AGENCY
I 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
Lenders Address
1 certify that 1 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 authorise mpresematives of this city to enter upmn the
ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify pod keep harmless the City�.of Cupcnino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICA DERSTANDS AND WI PLY WITt{ ALL NON -POINT
SOUR EG AT ON 4 _
Sign of Applicant/Contraetor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municip I Code. Chapter 9.12, and �hc Health and Safety
Code, Section 25532(a)?
❑Yes ONo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dbfincd by the Bay Area Air Quality Management
District?
❑ Yes O No
I have rdad the hazardous matc0als requiremcns undcrChapter6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not cot have a mnaat that it ism ponsihilky to notify the occupant of the
rcqui ens tch mint 'or ^ ante of a Certificate of Occupancy.
CENTRAL BAY CONSTRUCTION I PERMIT NO.0 6 0 8 0 011
36
(b31)763-3811
PERMIT ISSUE DATE
6
SANITARY NO, CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
TENANT IMPROVEMENT / DEMISING WALL
Ft. Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
4800
on
Occupancy Type
Date 1_; -_
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.
Signatureof Applicant Date
. All roof coverings to be Class "B" or better
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