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CITY OF CUPERTINO
BUILDING DIVISION PER*
----------------------
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
D TE
HEWLETT PACKARD
1600 SEAPORT BLVD STE 50
01 30 2007
PHONE:
SANITARY NO. CONTROL NO.
(650)216-3643
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70W) ofDivision 3 ofthc Business and Professions Code. and my license 'a
REVISION: ADD SMOKE DETECTORS, PENETRATIONS
in full force and effect S( O
License Class Lic.a u
THROUGH EXISTING COORIDOR, DELETE DISPLAYS AND
Dates O"l Contractor
ARCHITECTS DECLARATION
ADD
1 understand my plans shall he used as public records
ACRYLIC.PANELS.
Licensed Professional
OWNER -BUILDER DECLARATION
'
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which regoires a permit to conswum alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to of the contracture License Law (chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant the provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
5 0 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
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 (S500).
31607044 .
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
es
will do the work, and the structure is not intended oroffered for sale (Sec.7044,Business
and Professions Code: The ContractorLicense 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 Contractors 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 not exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
-
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hove and will maintain a Certificate or 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.
❑ 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 Workers Compensation Insurance carrier and Policy number arc:
Carrier. i.Lr"• In F?(vH.ei'icOlVdlicyNo.: 30.70"7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPUCANT: If, after making this Certificate of Exemption. you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
)
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
' the work for which this permit is issocd (Sec. 3097, Civ. C.)
Lenders Name
'
,
Lenders Address
I certify that I have read this application and state that the above infornatiun is
' correct. 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
ahove-mcmiuned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue against said City
' in consequence of the granting of this permit.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
U I ' (& i /'
UPAI
;g,
Issued by: Date
Re -roofs
natplr anUConuactor Dar
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as damned by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code ,Scction25532(a)? /
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ,(7 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 materials for inspection.
District?
❑ Yes Nu
1 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
dots n t currently have a tenant, that it is my responsibility to notify the occupant of the
menu hic bemetpp.or. isfuancc f certificateofOccup ex
Signature ofApplicant Dale
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All roof coverings to be Class "B" or better
or authorvcd agent D Ic