06050029 q
CITE'OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
DPR CONSTRUCTION INC PERMIT NO-06050029
10123 N WOLFS RD PERMIT ISSUE DATE
"vER'S NAME:
LANDMARK PROPERTIES 1450 VETERAN SANITARY No. CONTROL NO.
LARCHrrECT/ENGIN
E:
(650) 474-1450
BUILDING PERMIT INFO
EER: BLDG ELECT PLUMB MECH
i w a LICENSED CONTRACTOR'S DECLARATION Job Description
w C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
C i m with Section 7000)of Division 3 of the Business and Prgfc 'onsyric.pnd my license is TEMPORARY 1 HR TUNNEL
>>m in full force and effect C�j6
v�Z License Cla Lic
E a Datc ! �Contractor
ARCHrIECCS DECLARATION
U1 understand my plans shall be used as public records
t H Licensed Pmfcssional
.u OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
no following reason.(Section 7031.5,Business and Professions Code:Any city or county $20000
Q^ which requires a permit to construct atter,improve,demolish,or repair any structure Valuation
rA prior tri its issuance,also requires the applicant for such permit to rile a signed statement Sq,Ft.Floor Area
-Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
YF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 er
not more than five hundred dollars(5500).
0 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 docs 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.It,
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
sale.).
0 I,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-
cense Law does not apply to an owner of property who builds or improves t hemon,and•
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec B&P C for this reason f
,r Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 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 1
work for which this permit is issued.
0 I have and will maintain Worker's Compensation Insurance,as required by Sectio
3700 of the Labor Code,for the performance of the work for which this permit 6 issued.
My Worker's/j ompeasation Insurance carrier and Policy number arc• \ '-
Carrier. Atl eQ &. Policy No.: �O,�' V
CERTIFItLk E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhis section need not be completed if the permit is far one hundreddollars(E01
I
or less.)
I certify that in the performance of the work for which this permit is isst I all not
employ any person in any manner so as to become subject to the Workers'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
0 z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
Fr ham• I hereby affirm that there is a construction lending agency for the performance of
p�> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
a Lender's Address
z
U 0 1 certify that 1 have read this application and state that the above information is
GI.F correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction.and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection pu sea.
0.
0-4
(We)agree to save,ind cf and p harmless the City of Cupertino against
0-4 to liabilities,judgments,costs and ex hch may in any way accrue against said City �r
U`Z in consequence of the granting o s pe it. Date � 2 `i—.6 e-
t-- APPLICANT UNDER A S N ILL COMPLY WITH ALL NON-POINT Issued by:
SOURCEREGULA S _2�
Re-roofs
Signature of Appli ontract Dare Type of Roof
AZARDOUS 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
le,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
11 Yes
I If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment ordevices whicn all new materials for inspection.
emit hazardous air contaminants as defined by the Bay Area Air QualityManagement
District? �-�N�
0 Yes -M
1 have read the hazardous mate' quirememc under Chapter 6.95 of the Califor-
LHcalth&Safety Code, 'ons 533 and 25534.1 understand that if the building
rrently have Want. it' my responsibility to notify the occupant of the Date
ts which be or i ancc of a Certificate of occupancy. Signature Of Applicant
lZ"�� All roof coverings to be Class"B"or better
authariz d a t Date'