04010140 (2) CI'T'Y OF CUPEWrINO
Bmuanc D)vlsloN PT;RMIT CQNTRAG~TQR INFORMATION:
,.
BUILDING ADDRESS: PERMITN004010140
21 000 2TR17RNS CREEK PD
ER'S NAME: PERMIT ISSUE DATE
PHONE: - SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
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LICENSED am hummed
unORSder
DECLARATION Job Description
u I botchy affirm that I am Iianud under provisions of Chapter 9(commencingP
z,y with gcaion 7(g10)nfDivision7 of the Business and Pmfmsinm Coda.and mylicenu is FIN ��D
< in full force and affect, ,V
License Clear Lt..g TI--T MOBILE
nFn Dem Cummctor sSQO4
Q ARCHITECTS DECLARATION MAR 1 5 L
!!3 I to de.ou d my plana shall he uud p public scar&
Dyu
3 iJ t; nt
Licced Professional
3 OWNER BUILDER DECLARATION BUILDING X 1 hereby affirm tract
that I am exempt from the Contractors Liccnu Law for the
OO following reason.(Seedun 703 1.3,Business and Profeasiona Code:Any city or county
K B K which acquires a permit to construct,After.improve,demolish,or repair any structure
Yi< PH.,or its issuanee,alsu acclaims the applicant for such permit ro flea signed statement
EiG that he is licensed pmsmn0othe previsions of the Convactor'sLicensoLaw(Chapter 9 Sq.Ft. Floor Area Valuation
zi- (commencing with Second 700B)of Division3 of the Businassand Professions Code)or
i $ Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicantm a civil penalty a( 3lif$er00 Occupancy
nm mom roan five hundred dollars($5M). P Y Type
❑1,As owner or the property,m my employees with wages As their sole compensation,
will do the work.and the structure it not intended at offered for sale See.70,14,Business
Add Pmfundent Cade:The Contactors Liceme Law does oat apply m In owner of Required Inspections
property who builds orimproves thereon,and who daasuch work himself orthrough his
own employcea,provided Nat such improvemenu ve not intended oroffered for sale.If,
however.the building or improvement is sold within one you of completion.Ne owner.
builder will have the burden of proving Nu he did nm build or improv for purpose of
plc J.
A owner of Or,properly,em pclusively contracting with licensed contractors to
court the project(Sec.7044,Business and Professions Code:)The Contractor's U.
came law does not apply to an owner of property who builds or improves theater,And,
who contacts far such projects with a contractor(s)licamed pursuant to the Contractors
Lice nu Law.
❑lam cure/aga�der Sec. B&P C for Of,..an
DRKEFSCOMPENSATION DE TION
IhcrtbY affimt under penalty of perjury ore ar ]awing deductions:
❑1 have and will maintain a Ccnificam of Consem m calf-insure rte Workcre Compare
cation,As provided for by Section 77M of the labor Cade.for the performance of the
work for which this permit is issued.
CI I have and will maintain Workers Compamation Inv..p required by Stefan
37M of the labor Cede,for the performance of the works for which tua permit is issued.
My Wader's Compensation Insurance carrier and Policy number art:
Carrier. Pol icy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE .
Thu.sectimi reed not be,mend.md If the permit is far one hundred d.1hes($101))
mlcp.)
1 certify,Nu in the perforri of the wart for which this permit is isued.1 shall not
employ any Flood in any manner so as at become subject o the Workeri Complandor
Laws of California.Dale
Applicant '
NOTICE TO APPLICANT.If.after making this Cenifmam of Exemption,you should
become subject t.the Worker's Comptratumn provisions of the Late Code,you..at
.,O forthwith comply with such provisions or this Permit shall he deemed revoked.
„D,n" CONSTRUCTION LENDING AGENCY
.�. Ihereh affirm that there its construction lending f"' Y g agcayfor the Pcrfurmena of
fixthe work fur which Nis permit is issued sec.W,Civ.C.I
hQ Lenders Nam.
Z Lenders Address .
U Q 1 qday Nu 1 have rod this application and sum that the show information is
Fconal agree to agto comply with all city and county ordinances and sou laws relating to
C) U building construction,and hereby authorimrepresenutiva of this city to cater upon tM
(„� 1 (We)agree to gave.Indemnify and kap humlell the City of Cupenino against
Z inc....u.cmenu,costs and espemesmiich may in any way eceme against City
UZ atcPLICAN ce of the UNDERSTANDS
of this Permit.
APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOU REGU/yATIONS.
�SigqjuumarnphC,noc cuor D, g Re-roofs
ta
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
p darned by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
c,Section 35531(.)? All roofs shall be inspected prior to any roofing material being installed.
- 0Ym "Pi,
Will the applicant or future building act apart use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
samnua air contaminants as defined by one Bay Area Air Quality Management all new materials for inspection.
i6?
❑Yrs u
I have maul the bapNmduraurialsayuimmcnu under Chapter 695 aide:Califter.
all Health&Safety Codc.Sec..25505,75533 and 25534.Iundeatand mi(Ihe building
dots not currently have a mann.tom it u my mapotuialityrm noufy t ncc pant or ile
myuii,�nm inchmm't-74 metjteiap,ra ar acediEmmer ,n �sfl S ignature of Applicant Date
Ow�m or atommed.,cut Data All roof coverings to be Class "B"or better