07020093 CITY OF CUPERTINO Z (7�RM4TIE7�N;;
BUILDING DIVISION PERMIT � � �
.....;c
PERMIT NO.
BUILDING ADDRESS:
10744 STEVENS CANYON RD STEVENS CANYON LLC 07020093
PERMIT ISSUE DATE
OWNER'S NAME:
STEVENS CANYON LLC 10744 SANT ARY NO. CONTROL NO.
)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p C LICENSED CONTRACTOR'S DECLARATION Job Description
%m PI hereby affirm that I am licensed under provisions of Chapter 9(commencing
j Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REV I S I C IST• ROOF FRAMING, COVERS ALL PERMITS
in full force and c1I;QL 91
License Cnt�nnr ORIGINAL: 06050140
;:LU Date *#A CHITECI S DECLA A
to
j a< 1 understand my plans shall be used as public records
)qU
'u.y Licensed Professional
a OWNER-BUILDER DECLARATION
1w.J
I hereby affirm that 1 am exempt from the Contractor's License Law for the
pO following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
—y prior to its issuance,also requires the applicant for such permit to file a signed statementFt.Floor Area Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S�]
e.H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $511898
1. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ��PN` Number
not more than five hundred dollars(5500). 35603047 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.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
sate.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
ccnse Law docs 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.
C]I am exempt under Seo. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑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
worktch this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
1liCartier. . � Pocy r
-CERTIFICATE EMPTION FROM
WMERSr
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ane hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workcrs'Compensation
Laws of California.Date
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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
E r 1 hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
z Lender's Address
I certify that 1 have read this application and state that the above information is
U
O correct.I agree to comply with all city and county ordinances and state laws relating to
CU building construction,and hereby authorise representatives of this city to enter upon the V
Lr i above-mentioned property for inspection purposes.
Q. (We)agree to save,indemnify and keep harmless the City of Cupertino against
C/) liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the ming of this permit. Date
APPLICA TANDS AND W1 COMPLY WITH ALL NON-POINT Issued by:
SOURCE ONS.
11A (0 Re-roof:
Sign rc of Applicant/ConUactor te Type of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof 3 shall be inspected prior to any roofing material being installed.
❑Yes Ip ry°
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment ordevices which all new materials for inspection.
emit hazardous air contaminants as defined by the Bay Area Air QualityManagement
District?
❑Yes 01N.
I have read the hazardous materials requirements undcrChapter 6.95 of the Caliber
nia Health&Safety Code,Secuons 25505,25533 25534.I understand that if the building
docs not cu tenant,that it is my nsibility,w notify the occupant of the Date
reyuiremcn w tbemet rwiss cco[aCerufica Signature of Applicant
All roof coverings to be Class"B"or better
Owner or authonzcd agent ate