07120264 CITY OF CUPERTINOa ;�
BUILDING DIVISION PERNHT CgNTRACr =OR�IrTF'URNIATION
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BUILDING ADDRESS: PERMIT N0.
10150 N WOLFE RD (JC PENNEYS) TBD — TO BE DETERMINED 07120264
OWNER'S NAME: FEM97 ISSUE DATE
CUPERTINO SQUARE 03/27/2008
ONE: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Sop LICENSED CONTRACTOR'S DECLARATION I Job Description
v6 1 heinaffirm that afal l am licensed under provision of Chapter 9(commencing P
wide Sectkn70()0)orDivemn 3.rft Basin.and Pmreuiom Code.and my license is T. I . —FACADE IMPROVEMENT—JC PENNEYS.
_)Mn H in full force and efface
RZ U"nse Class Lk.g .
4 Date Contractor
�aARCHITECTS DECLARATION
1 understand!mY Pla
2 ns Mall he used u public retards
h std Licensed professional
y 3 OWNEWBUILDER DECLARATION
I hereby aTrm that 1 em exempt front the Commerm's License law for the
00 following moon.(Section 70313,Business and professions Cade:My city or county
IE! which requires a permit he emmncL alter,improve,demolish,or repair my suuctum
_Z'y^ prior be its issuance.also inquires the applicant porsuch permit to rile a signed mmmant
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that he a licensed pursuant to Neprevisiomcepthe ConuacmrtLicense Law(Charter 9 Sq.Ft. Floor Area Valuation
Ea ceF$ (commencing with Section 7000)of Division of the Business and profession Code)or 40�0�
that he is exempt themfnn and the basis for the alleged exemption.Any violation of
Swtion 7071.3 by Lary applicant for a permit subjects the applicant m a civil penalty of -
Number Occupancy Type
not moan Nu five hundred dollars(SSW). 316 2 0 0 9 4 PdV
❑I,ma roftbepmpeny,nrmymplorawidewgesudeeirwkcompenssdon,
will do the work and destruction a not intended ar olTamd fmsele(Secn...
.Wlxt,Bud
ate Pmressions Cade:Tete Camnemn License Law does ant apply m an owner of Required Inspections
property whoa huildsmirepmvesdeercon,and who dassech work himselrm Waugh his
awn employees,pmvlded that such improm menu one notinunded oroRered trestle IL
however.Ne building or improvement esold within con year of completion.We owner.
builder will lave the burden of proving that he did int Wild or improve for purpose or
ask.).
1,as owner of the property m ueluively contracting with licensed contractors to
eomtroct(M project(see.Sae.Business and Pmlesdons code:)The Contractors u.
cense law doer not apply us an owner or property who Wilds or imp om thescon,and.
who contractslonwhp uwideaeanuwata(q licensed punumtb the Co trantota
License law.
❑1 m esmps under ,B d ( Nis n
Owner Da
0 KEWSICOMFENSATION DECLARATION
1 how"'"'I'm
underpemlty o(perjmy ane of the following emse hos:
I haw and wfll mon Wn a Cenificau ofConsem to self.imun lm Wafte.Compere-
m,u provided fee by Section 3700 of the labor Cads.fm the performance of dee
work for which Nis permit is issued
❑1 have and will maroon Workees Compensation Insurance,as squired by Section
37Wafthe lacer Code,for the performance of dee work forwhich the permit a issued '
My Waukee,Componsstian Wsttnn"esrim and Polity number m:
Cameo Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(The suction wed notbecomplcad trim permit is throne hundred dellen($10a)
mina)
1"rely that inthe oynan h wort r which the permjr a it='yti.1 shall not
employ anY permn /manner b =subkclmOa YmbrsRern�emakee
Laws of Califam' /
Applicvnt /
NOnCE TO AP LItAW.IL after me he Certificate of Exemption,you shouW
becmne moat in dee Worker's Compensation provisiom of the Law Code,you must
.J O
551 fonewith comply what such provisions or the permit shall M demand red revoked.
CONSTRUCTION LENDING AGENCY
IMreby arum Nat then is a enmwetim lending agency far the perfumm"up
M the work for which this permit 6lased(See.307.Ci,.e.)
LT)/1 Leaders Name
Fzl under,Adder••
U O 1 comfy that l have read this appfrestion and cum Nu the shave intonation is
Ly F+ comate I agree m comply with a!1 city and county onsinareca and ante laws meting to
�U building convection,and hereby anNarien representatives of the city as caw upon the
W above-mendoned property for Inspection purposes
(We)agree to an,indemnify and kwp hamiess the City of L'upemno against
y Ilabilides,judgmenu.cmu and expenses which may in my my aacrwagaionsed City
C.)z A P ICA we of the Ong a(/h' il. -
^ APPLICANT UN -ND A IL OMPLY WITH ALL N N-P01 Issued by: Date
SOURCE REGI S.
Re-roofs /
Signum.1'ApplicirtaXwwwwr Data v
HAZARDOUS MATGu,L,oPqci OSURE Type of Roof
Will the Applicmt or future building oacopant stow or handle hasudam material
as defined by the CuWain,Municipal Cade.Chapter 9.12,and the Health and Safety
Code.DY.25532(a)? / All roofs shall be inspected prior to any roofing material being installed.
Will the applicat or future building occupant use equipment or devicm which If a roof is installed without first obtaining an inspection,I agree to remove
hit hmardwe arehmmimm; dentntl by that Bay Ama Air Quality Mmagmont all new materials for inspection.
an
❑Yin No
1hesemWWhaardaumada requinmenuunder Chapkr6.95oftheCalifm-
t4.-Aff Cade.Sa�pnwctad'-
334.ImtkrusnE if Ne Wi ding
'Rhy m wdfI, o"upanfW Signature of Applicant Date
ower r.nthaaac agent DimAll roof coverings to be Class'%q."or better