07060046BUILDING DIVISION PERMIT
E-4 ' RESULTS WAY
OWNER'S NAME:
EMBARCADERO CAPITAL PARTNERS
uNE:
ARCHITECIENGINEER:
p zO LICENSED CONTRACTOR'S DECLARATION
VI hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business ani Profusions Co d y license is
"40. in full force and eft !/7
r ? License Cl Lic. # ai
p Date Contractor
r AR GTS DECLAR I R Ki t �p/�r
i C < I understand my plans shall be used as public records J
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U. y Licensed Professional
O a OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
: n O following reason. (Section 703 1.5, Business and Professions Cale: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
r " ( prior to its issuance, also requires the applicant for such permit to file a signed statement
Z < that he is liecnsed pursuant to the provisions of the Contractor's License Law (Chapter 9
4 F (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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 of
not more than five hundred dollars ($500).
0 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 for sale (Sec. 7044, Business
and Professions Code: The Conuacules 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.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Cootracwes L -
case Law does not apply to an owner of property who builds or improves themon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec. B & P C for this reason
^•vner Date
WORKER'S COMPENSATION DECLARATION
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PERMIT NO.
TBD TO BE DETERMINED 07060046
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
T.I—STRUCTURAL—ELECT/MECH/PLMBG. THE EMP'S WERE
ADDED IA ON THE 2ND RESUBMITTAL. FEES WERE
UPDATED 7/25/07.
I hereby affirm under penalty of perjury one of the following declaratio=
-1 I have and will maintain a Certificate of Consent to self -insure for Workees Compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
-1 I have and will maintain Worker's Compensation Insurance, as required by Section
5700 of the Labor Code.�°&r the performance of the work for which this permi is issued.
Ay Worker's and Polity rare:
Carrier: ` Policy N
CERTIFIE OF EXEMPTION FRO
CATRK
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. I shall not
employ any person in any manner x 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
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 issued (Sec. 3097, Civ, C.)
Lender's Name
Lender's Address
I certify that 1 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
building construction, and hereby authorim representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments asts and expenses which may in any way accrue against said City
in consequence of c granting of this rmit.
APP ICANT U RST WI WITH ALL NON -POINT
S G
Si nature [/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Codc. Chapter 9.12, and the Health and Safety
^ode, Section 25532(a)? ,1
0 Yes No
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
District?
0Yes o
1 have read the hal rws materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a ttant, that it is my rMonsibility to notify the occupant of the
.,...... of a Certificate of Occupancy.
or authorized agc f Date
q. Ft. Floor Area
35720042 .`VV
Issued by
Re -roofs
Valuation
$650000
Occupancy Type
Required Inspections
Type of Roof
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
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class "B" or better
Date