07010039 CITY OF CUPERTINO � TRItF� IlR1WiTN'
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
10123 N WOLFE RD DPR CON '' PERMIT ISSUE DATE
�GWNER'S NAME: 14 5 O VET]BRANS BLV 01/05/2007
VALLCO/LANDMARK _
SANITARY NO. CONTROL NO.
,ONE: (650) 474-1450
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG EG LECT PLG]UMB MECHG
0 p LICENSED CONTRACTOR'S DECLARATION IOb D6SCrlptlOn
4"1 F I hereby affirm that I am licensed under provisions of Chapter 9(commencing GAS LINE TRENCH FOR RELOCATED LINE FOR GAS METER
=z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
"�y in full force and effe G9 4 ROOM
j rn z License CI Lie.N
Date ` Contractor
3 r ARCHITECTS DECLARATION
a< I understand my plans shall be used as public records
�yU
tL H Licensed Professional
< OWNER-BUILDER DECLARATION
n'^-J
I hereby affirm that I am exempt from the Contractor's License Law for e
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.4,�, which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation
y—y prior to its issuance,also requires the applicant for such permit to file a signed statement $1.Ft.Floor Area $1500
—?< that he is licensed pursuant to the provisions of the Contractor's Incense law(Chapter 9
Y H$ (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 at Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 16 2 0 0 6v
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation. Required Inspections do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or impmves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.11.
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.).
0M'as owner of the property,a excl vely contracting with licensed contractors to
construct the project(Sec.7044 us and Professions Code:)The Contractors Li-
cense Law does not app) nej f properly who builds or improves thereon,and
who contracts for such wi ntractor(s)licensed pursuant to the Contractor's
License Law. B 1k P C for thytrcasoy
❑lam,
am exempt un c iv I
Owner °are�—
ORK 'S COMPENSATION DECLARATION
I hereby afrima under penalty of perjury one of the following declarations:
I]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.
❑1 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 Workees Compensation insurance carrier and Policy number are:
Carrier. Pot-icy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
OM ENSAMON INSURANCE
(Mis section nee not omplcted if the permit is for one hundred dollars($100)
or less.) /
I certify that in the rf(' cc of the work for which this permit is issued,t shall not
employ any perso n anncr Joh&11?cgloe�rbjCct to the Workers'Compensation
Laws of Caltfo a C7
Applicant
NOTICE TO U :If,after making this Certificate of Exemption,you should
become subi the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
Q!+> the work for which this permit is issued(Ser:.3097,Civ.C.)
W Q Lender's Name
04 Lendees Address
1 certify that I have read this application and state that the above information is
LUL� cortect.I 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
U ahove-mentioned property for ipspcc'dn rposes.
(We)agree to save,in mnif cep harmless the City of Cupertino against
fa. liabilities,judgments,costs sAd ex Erse which may in any way accrue against said City
inconsequence
of
ng o a rmit. Date ""��L 7
C)Z APPLICANT U AN D WILL COMPLY WITH ALL NON-POINT Issued b):
SOURCE R S.
Re-roofs
Signature pli t/ atracor °ate T Of IZOOf
H DOUS 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.
❑Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devic devices all new materials for inspection.
,mit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes
►havcreadthehaz rd aterials uiremcntsunder Chapter 6.95ofthe Califor-
niaHcalth&SafctyC 25505 533 and 25534.1undcrstandthat ifthe building
docs not currently a tfn 4 that' u ponsibility to notify the occupant of the Date
requirements wh' et p assu cc ora Cenirtcate of occupancy. Signatur'of Applicant
All roof coverings to be Class"B" or better
Owner a a ed ag t Date