06120041 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C fit'► ICIR �TI€IN
PERMIT NO.
BUILDING ADDRESS:
1026R BANDI -Ev DR #3 02 _TBD_—__T_C, IDEEPERMINEE)
OWNER'S NAME:
MAY' S TAX 01/23/2007
SANITARY NO. CONTROL NO.
JNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0 o a
4 p 0O LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
_.z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is T I . OFFICE SPACE, ELECTRICAL/MECHANICAL
e y in full force and effect
z License Class Lic.p
t
Date Contractor
Contractor
uARCHITECTS DECLARATION
99"
C< 1 understand my plans shall be used as public records
JaU
u,i- Licensed Professional
=0< OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
r p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
m 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 rile a signed statement Valuation
Z< that he is licensed pursuant to the provisions o[the Contractor's License Law(Chapter 9 iq.Ft. Floor Area $90000
%F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
U
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 of3263309"
APN Number Occupancy Type
not more than five hundred dollars(5500).
❑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 rot 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
We.).
1,as owner of the property,am exclusively contracting with licensed contractors to
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 contractors)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S C011 P NSATION DECLARATION-/
I hereby affirm under pct of perjury one of the following declarations:
Q 1 have and will maintain a Ce to 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. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work[or which this permit is issued,1 shall not
employ any person in any manncrso as to su' to ret rs'Cmmpensadon
Laws of California.Ike
Applicant
NOTICE TO APPLICANT:If, r making Ilds Certificate of Exemption,you should
become subject to the Worker ompensation provisions of the Labor Code,you must
,Z forthwith comply with such to isions or this permit shall be deemed revoked.
Z O CON UCTION LENDING AGENCY
[~"►�-� 1 hereby affirm that there is a construction lending agency for the performance of
fy+ the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lender's Address
U 0 1 certify that I have read this application and state that the above information is
[>~ correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
P. (We)agree to save,indemnify and keep harmless the City of Cupertino against
te
r- v) liabilities,judgments,costs and expenses which may in any way accrue against said City �J `
U Z in consequence of the granting of this permit. Date
O-+ APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON-POINT Issued by.
SOURCE REGULATIONS. , 0
Re-roofs
Signature of Applicant/C in Dae Type Of]:OOT
H'M O S MATERIALS DISCLOSURE YP
Will de applicant o tit building occupant stoic or handle hazardous material
as defined by the Cupertino un ipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Lam°
� If a roof s 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 materials for inspection.
District?
❑Yes pa No
I have read the hazardous\materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which ot prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
``- a All roof coverings to be Class"B"or better
r a
Owner outhori-zcdant ae