08020112CITY OF CUPERTINO
BUILDING DIVISION
BUILpjI�Jji�( DIES$k . WOLFE RD
OWNE1R'(SJNA�jMEj: j�
KIMCO REALTY CORP
PHONE:
ARCHrrECT/EJGINEER:
i O Yp LICENSED CONTRACTORS DECLARATION
co U I hereby affirm that I am licerwd under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and fessimu Code, and my license is
n full form and R 'L e6(l bb 3 (�
j i License Clan Lic. a
F o Dale Contractor US 1hOs s
ARCHFECI-S DECLARATION
U 1 understand my plans shall be used as public records
>yU
u, H Licensed Professional
7 OWNER -BUILDER DECLARATION
qy 1 hereby affirm that 1 am exempt from, dic Contractors License Law for the
no following reason. (Section 7031.5, Business and Professions Code: Any city or county
� ff which requires it permit to construct. alter, improve, dernolish, or repair any structure
y y prior to its issuance. also requires the applicant for such permit to fik a signed statement
< that he is licensed pursuant to the provisions of the Cont actoet License Law (Chapter 9
o (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y 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
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❑ L as owner of the property, or my employees with wages as drk sole corn=don,
will do the work and the structure is not intended tan offered for sale (Sec. 7044, Btrdtrcas
and Professions Code- The Contraua's License Law does ant apply to an Owner of
property who builds or improves thereon, and who does such work himself or thrvagh his
own employers, provided that such improvements are not intended or offered for ale. 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
ale.).
❑ L as owner of the property, am exclusively contracting with licensed contrsctnra to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's U.
comae Law does 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 sm exempt under Sec , B & P C for this reason
Owner tote
WORKER'S COMPENSATION "ON
I hereby affirm under penalty of perjury one of the following declandortt
❑ 1 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
❑ 1 have and will maintain Workers Compensation Insmancr, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
My Wor s Compensatiam Jp—aurance carrier and Policy number am: r }
Cartier: �� I PolicyNo.: J 6 f J
ERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Curls section need not be completed if the permit is for one hundred dollars ($100)
or lee)
1 certify that in the perfohnanee of the wort for which this permit is issued. I shall not
employ any person in any manner so u to become subject to the Workcrx' Compensation
Caws of California. Dec
Applicant
NOTICE TD APPLICANT: If, after making this Certlricatc of Exemption, you should
become subject to the Workers Compensation provisions of ate Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION 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, C(v. C.)
Lenders Name
Lender's Address
I eerdfy that 1 have read this appliaion and sate that the above Information is
coned. I agree to comply with all City and county ordinances and state laws relating to
building construction. and hereby authorise representatives of this city to eater upon the
above -mentioned property for Inspection purposes
(We) agree to ave. indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costa and expenses which may In anyway accrue against said City
in consequence of the An
' g of this PCMIL
APPLIC UNDER NDS AND WILL COMPLY WITH ALL NON POI
SOUR U DE
A__ �
Signature of ApplicanuCon r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑ Yes f] No
Will the applicant or future building o=pant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Disuict7
❑ Yes
1 have read the banrdou s materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety godc. Sections 25505, 25533 and 25534.1 understand that if the building
does not nth w a L that it is responsibility to notif the i of the
Y Y respo Y Y
mquirc whit must) met odor to issuance of a Ccnifhcuc of Ocdu'artcy
1'ercM11 NU.
TBD - TO BE DETERMINED 08020112
DEMO,INTERIOR-RMV
Sq. Ft. Floor Area
APN Number
Re -roofs
'Type of Roof
PERMIT ISSUE DATE
02/19/2008
SANITARY NO, CONTROL NO,
BUILDING PERMrr INFO
BLDG EIECT PLUMB MECH
Required Inspections
Valuation
Date 'Z , / 9_
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 "B" or better