06120114 CITY OF CUPERTINO �� IT :
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: id
19111 PRUNERIDGE AV SWINERTON B PERMTr ISSUE DATE
OWNER'S NAME: 19 9 5 LAUR ELWOOD RD 1/12/2007
HEWLETT—PACKARD
SANITARY NO, CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITEC IFNGINEER: TI COMMEF ICAL OFFICE SPACE— BLDG ELECT PLUMB MEC14
'.100 LICENSED CONTRACTOR'S DECLARATION _, Job Description
4U C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=Z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is
03 M y in full force and effect.en
3n? License Class Lic.#
—p Date 1--j2.0 n7. Contractor
A CH=rM S DECLA ATION
Jac I understand my plans shall be used as public records
�yU
u y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
Kms,E which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation
Z y prior kt its issuance,also requires the applicant for such permit to tilt a signed statement Ft.Floor Area
that he is licensed pursuant to the provisions Of the Contractor's License Law(Chapter 9 q'
YF-- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy T e
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number P Y YP
not more than five hundred dollars($500).
0 I,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 imprnves 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.).
0 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.
cense taw 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-
C3 B&P C far this reason
1.
exempt under Sec.
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury Otte 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
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My workces Compensation Insurance carrier and Policy number arc:
Carrier. �fid/ LA AA9 ?-y No.:WL�fi ff �'9—0
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 for which this permit is issued,l shall 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
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
F~•r— 1 hereby affirm that there is a concoction lending agency for the performance of
> the work for which this permit is issued(See.3097.Civ.C.)
(fa Q L.endces Name
a z Lender's Address
1 certify that I have read this application and state that the above information is
L)
0 correct.I agree to comply with all city and county ordinances and state laws relating to
building concoction,and hereby authorize representatives of this city to enter upon the
0 U
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Zin consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b3:
W�saell�o� I�IZfW� Re-roofs ,
Signature of Applicant/Contractor D T of Roof
MATERIALS DISCLOSURE ype
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.
0 Yes
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
-.nit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? /
0 Yes MI6
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
reyuirem is hich st be met prior to issuance Certificate of Occupancy. Signatur,-of Applicant Date
U All roof coverings to be Class"B"or better
Owner or authorized agent I D