07100042CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.BUIUf~~5!(fESf.j TANTAU AVE OPI COMMERCIAL BUILDERS 07100042
PERMIT ISSUE DATEOWNER'S NAME:
FOUR CORNERS PROPERTIES 445 LEIGH AVE #100 12/18/2007
SANITARY NO. CONTROL NO.PHONE: (408)377-4800
BUl1.DING PERMIT INFO
BLDG ELECT PLUMB MECH
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ARCHTTECTIENGINEER:
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C~ E: I hcn:by amrm lhall ara licensed under provision. of CbaPlcr 9 (commcncin& Job Description
~~ ~ with Section 7(00)of Division 3 oflhc Busi=and Professions Code(a"}"'y license is COMML TI ON "EX I ST ING 0 FC BLDG i T-BAR
_::> '" in. full forte and crrCCl.~ . (//2 :=I?l:l! LICense 0.... _ Lit. _ _ +~..J/,,:,1f.;L.!::;.1,;-'=-"o----2...:./.~..!-----
• - 0 OalC /_L)= ~ ConlrllClOro~~-~:;_=~===----+ ~ !: w t ~ .(RCHITECTS DEC' RAT ON ~ ;]::l I undcrSland my plans shall be used LS public =rdl
) ~ ~ I ""--:-::---;-:.-;---;------------------<.. !;; Licensed Professional ~o :5 OWNER-BUILDER DECU.RATION
I hereby affirm thai I am ....mpl from ill. ConlTilClor'. License Law for \he~S:li_00 followin& reuon. (Section 7031.5, Business and Profc.<Sions Code: Any cily or county ~~Il:which requires a pcnnil to consllUCt. a.ILer. improve:. dcmolb;h. or rcpMr any slruclW"C.-",prior ID ilS issuance. also requires \he applicanl for su.h permillo file a si&ned slalCmen! f--------:::-~;-=~-_;_--------r_---------;:-:-~-:----------_z >
~ s: ~ thll he is licensed pursuanllo th.provision.,of th.ConlnclOr's Lie..nse Law (Chapler 9 Sq -Ft.Floor Area $83 0000 Valuation
(comm.ncing with Section 7(00) of Divi.ion 3 of th. Business and Professions Code) or
e~-Ibat he ia exempt therefrom and lbc basis for \he alleg.d exemption. Any'violation of I --------;-;:~~;-,,__=_-------f_------~------;=---------
Section 7031.5 by any applicant for a permh subjec... the aPlllieanllo a civil penally of r 31601906..A.P 'N..Number Occupancy Type
;: ... :iii
1101 mo", than rave buodred dollars (S500). .t ~ t1 V '
o I. as owner of the propcny. or mycraploycea with _g= aslhcir sole compensation. I L _
will do the won:. and the sUUclu", is not intended or offered for sale (Sec. 7044, Bu.sinoss r
and Professions Code: The Conlnetor's Li.ense Law docs not apply 10 an owner of Required Inspections
property who build. oriraproves \hereon, and who does such work hlmsclf or througb bis
0W1l employees. provided thll such improvemen... ue not inlended or offered for sale. If.
however, the building or improvement is sold willtio one year of completion, the owner-
builder will have Ille burden of proviog thit he did nOI build or improve for purp= of
Slle.).
o I, LS owner of the propcny. ara exclusively coolt1Cling \Vilb licensed eonlTilclor. 10
coo.uucithe projeCl (Sec. 7044. Business and Professions Code:) The ConlTilClDr's li
cense Law docs nOI apply ID an owner of propcny who build. oriraproves the",on. and ,
wbo conU'acLs for such projects wilh a conlraetor(s) liccnsc:d pursuanllO I.be Con1.raCtor's
License Law.
o 1= exempt under Sec. ,B '" PC for thi. reason
Owner ============-= _DaIC WORKER'S COMPENSATION DECURATION
I bereby affirm under pcnaIly of peljury one of Ihc following declarations:
o 1 hive and will maintain a Certificate of Conseotlo self-insure for Worker'. Compen
sation, .. proVided for by Section 3700 of th. Labor Code, for Ihc performance of the
work for which this pennit is issued.
o I have and will maintain Workor's Compensation Insw-ancc, .. n:quired by Section
3700 ofth. Labor Code, for the performance oflbc worl: for which litis permil is issued.
MY~orI:er'~mpe '0 nsuran carrieran~Policyn7ZZ3 y y
Carner. l. Pohcy No.: I U
CERnFl :IE 0 EXEMPTION FROM'WO S' I
COMPENSATION INSURANCE
(This section ncc<l nOI be complelea ifll><: permit is for one hundred doll"" ($100)
nr los..)
I cenify tha' in the performaoc. of lhc worl: for which this permll is issued, ( shall not
employ any person in any manner so IS ID become subjccl to the Workers' CompensatioDLaw. of California. Dale _
Applicant ==---:-:c--:-------,---,.,---;-:,--,----,.
NOTICE TO APPUCANT: If. aflCr making this Ccnificale of Excmplion. you should
become subject 10 lhc Worker's Compensation provisions of lhc Labor Code. you mllSl
forthwith comply with such provisiollS Of this rc~il shall be deemed ~k.cd.
CONSTRUCTION LENDING AGENCY
1hcn:by affinn UW there is ~ construCtion IClIdin~ I.~ncy Cor the performance DC
the worl: for which litis permil is issued (Sec. 3097, Civ. C.)Lender's Name _
Lender's Address _
1certiCy thll I hlvc read this application Uld SIaIC-that the above: infonnation is
COt'TCCL I agn:e LO comply with all cily and counly ot'tJinance.s and Slate laws ~Iatin& lO
buildint construction, and hen:by IUthOrin: n:prcscnlativc.s DC this cily to cnler upon the
abov.-mentioned propcny for inspection purposes.
(W.) a&",e 10 Slve. ind.mnify and keep harml.ss \he City of Cupenino a&ainS!
liabilities, judgmenlS. COSl.< and expensca which may in any ....y accrue agalnsl said Cily
in consequence of th. glCllting of thi. permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Isstied by:
Date
S~~_ (--)lP&,
Re-roofsS~tncun Care
HAZARDOUS MATERIALS DISCLOSURE Type of Roof ,~
'Willlbc applicanl or future building occupant store or handle hl7.an1ous malCrial
LS defined by the Cupenino Muni.ipal Code. OaplCr 9.12. and the Hcalth and Safely
Code, ~~ 2.5532(a)7 ~p«j 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
Will the applicant or fUf.;;.'building occupanl usc tquipmenl or devi ... which
emil hu.ardous ilir conwninanl3 IS defined hy lbc Bay Area Air Qualily Manageme.nl all new materials for inspection. .
Di,!riClbycs ~'
I have read lbc hl7.ard malCnals rcquin:mcnlS under ChaplCr 6.95 of the Califor
nia Hc:>lth '" SafclyCodc. Secti 2.5505.2.5533 and 2.55>4.1 uodcrsuu1d thalif\he building
docs not currenOy have a &cnanl, lhat it is my raponsibility \Q notiCy the occupant oC the
requirements which met prior 10 issuance oC a CcnificalC.gC Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better Owner or authori7.l:d agenl D.le '
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