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CITE' OF CUPERTINO
DIVISION PERMIT
C�'T'�;ACT�?RiINFQRMTI(�1�i�
BUILDING
BUILDING ADDRESS:
PERMIT NO.
10123
OWNER'S NAME:
PERMIT ISSUE DATE
LANDMARK PROPERTIES MGMT
2101 W:EBSTER ST, STE 1500
01/22/2007
.ONE:
SANITARY NO. CONTROL NO.
(510) 8:13 -5170
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
(_ 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
REVISION: MACY h S BRIDGE STRUCTURAL DETAILS
in full force and effect.
License Class Lic.N
ORIGINAL PERMIT: 06020109
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER- BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
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
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
Business Professions Code)
$11000000
(commencing with Section 7000) of Division 3 of the and or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
316 2 0 0 :; 7 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
.
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: 'Rte Conuactoes License Law does not apply to an owner of
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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
sale.).
❑ 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 thereon, and •
who contracts for such projects with a contractor(s) licensed pursuant to the ontractor's
License Law.
❑ I am exempt un B & P C r thi reason
Owner Date (!/}
WORKER'S C N eN DECLARATIO
I hereby affirm under penalty of perjury one of the following declarations:
❑ i hsve 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.
❑ I 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that in the performance o ork or:which this permit is issued, I shall not
employ any person i arm so o c object to the Workers' Compensation
Laws of California.
Applicant
NOTICE TO APPEtAINff. 11, after making this Certificate of Exemption, you should
become subject to the Workcr's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
1
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
j I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
' above - mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expe - which may in anyway accrue against said City
in consequence of the wing of r rmit.
APPLICANT U AN S WIL 'COMPLY WITH ALL
Issued b r, Date
VON�NT
SOURCE REG S.
Re -roofs
Signature App icon Contractor
of
HAZARDOUS MATERIALS DISCLOSURE
Type of . Zoof
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: shall be inspected prior to any roofing material being installed.
❑ Yes ❑ No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new I naterials for inspection.
District?
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
i
nia Health Safcty C lions 2 5.2 5533 and 25534.1 understand that if the building
/ 2
does no c rt fly ha a ant. at t js my responsibility to notify the occupant f they
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rcyuirc rich e ri o hssuancc of a Certificate of Occ pan
Slgnatur,; of Applicant Date
r f 2
All roof coverings to be Class "B" or better
Owrkr oY authorircd agent D tc