07010033CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
10123
OWNER'S NAME:
PERMIT I55UE DATE
LANDMARK PROPERTIES MGMT
1450 VETERANS BLV
1 22 2 7
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
REVISION: STRUCTURAL CHANGE
BLDG ELECT PLUMB MECH
0 o a a
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
in full force and effect -
License Class Lie.0
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby al7frm 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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN 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 (SM.
❑ 1, 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 Cod_ — The Contracuies 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
sale.).
❑ L as owner of the property, am, elusively contracting with licensed contractors to
construct the project (Sec. 7044. iness and Professions Code:) The Contractors Li-
cense Law does not apply to an of property who builds or improves thereon, and.
who contracts for such projectsAith a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt B & P C for this reason
Owner ! / Date
OR ER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑' 1 have and will maintain a CcniGeate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance or the
work for which this permit is issued.
- - -
❑ I have and will maintain Worl¢rs Compensation Insurance, as required by Section
3700 or the Labor Code, for the performance of the work for which this permit is issued.
'
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Poli No.:
CERTIFI70FEXEMPTI FROM WORKERS'
N URANCE
(This section need it 1s for one hundred dollars (S 100)
or less.)I
certfry dot in tier perforfor which this permit is issued. 1 shall not
employ any person in any come subject to the Worl rs' C p nsatio
Laws of California Date -c'
Appliance
NOTICE TO APPL I ; 11, aQ r making this Certificate of Exemption, you should
become subject to theNVorkers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUC77ON 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.)
Lenders Name
Lenders Address
I certify that I have read this application and sate that the above information is
correct I agree to comply with all city and county insnces and state laws relating to
building construction, and hereby aulhori ep tatives of this city to enter upon the
above property for inspectio p rpo
(We) agree to save, indcmn' n kee less the City of Cupertino against
lfabflities, judgments, costs and whi y in any way accrue against said City
'
in consequence of the granting
APPLICANT UNDERSTA A D vG COMPLY WITH ALL NON -POINT
Issued by: Date — 22
SOURCE REGULATION
Z _G
Re -roofs
Si nature or
g ApplitanUL` err Dater
US MATERIALS DISCLOSURE
Type of Roof
Will tfte appB t or future building occupant store or handle ha-ardons material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and safety
Code, st Yes 25532(a)?
❑ Yes
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the a licant n noire lain occupant use
pp g pa equipment or devices which
craft hitzmdom air contamirunts"as fined by the Bay Area Air Quality Management
all new materials for inspection.
Disuict?
❑Y o
1 vc hvat� materials requirements under Chapter 6.95 of the Califor-
nia Hera k s ty odc, Secaons 25505.25533 and 25534.1 understand that if the building
does t c tly MCA taunt that it a my responsibility to notify the occupant of the
mqu mcnts h nisi Aa met prier to issuance of a Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
O
r utho .cd agent Date