07070032 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � T ��
PERMIT NO.
BUILDING ADDRESS:
20920 MCCLELLAN ROAD CUPERTZnO ELECTRIC INC 07070032
PERMIT ISSUE DATE
OWNER'S NAME:
3T JUDE CHURCH 1132 N STH ST 09/06/2007
SANITARY NO. CONTROL NO.
PnuNE:
(408) 991 -1000
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0
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p p LICENSED CONTRACTOR'S DECLARATION Job Description
iV P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U U with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD 7 1"5 MH POLE F I XTURE S r 3 1 0 0 MH AND 3
:ZW.may in full force and t Lich 17`{(,3'7 V Ir RECEPTIC'LES
v�z License
F Date C Contractor
ARCHITECTS DECLARATION
aa I understand my plans shall be used as public records
)LU
U.H Licensed Professional
a OWNER-BUILDER DECLARATION
I hereby alTirm that 1 am exempt from the Contractor's License Law for the
.p Oy� following reason.(Section 7031.5,Business and Professions Code:Any city or county
rex which requires a permit to construct,alter,improve,demolish,or repair any structure
i"y prior to its issuance.also requires the applicant for such permit to file a signed statement Valuation
?< that he is licensed pursuant to the provisions of the ContractorFt.Floor Areas License Law(Chapter 3q 2 0 0 0 0
4 F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
1153 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 3592000
::8APANumber Occupancy Type
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections
and Professions Coude:The Contractor's 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Comractoes Li-
cense Law does not apply to an owner of property who builds or improves thereon.and.
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. ,B&P C for this reason
^,ner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑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.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code.for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Polityn/gmber are:
Carrier.Z_uxzc t4 ArlfezaCA Q Policy No.,NL e-3LI'31,!Q
00�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fox 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 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z t'-"' CONSTRUCTION LENDING AGENCY
Fr w'. I hereby affirm that there is a construction lending agency for the performance of -
Q!> the work for which this permit is issued(See.3097.Civ.C.)
W Q Lender's Name
z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
L> ►-� correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representativrs o!this city to enter upon the
W above-mentioned properly for inspection purposes.
F (We)agree to save•indemnify and keep harmless the City of Cupertino against
H liabilities,judgments,costs and expenses which may in any way accrue against said City > /�
t;,)Z in consequence of the granting of this permit. Date / �C� �
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: '
SO CE RE LATIQNS.
d Re-roofs
Signature ofA licantIC ntrad r 8e T of FLOOf
H USMATERIALSDISCLOSURE Type
Will applicant fu building occupant store or handle hazardous material
as defined b the Cupertino building
l Code.Chapter 9.12,and the Health and Safety
^ode,
Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof s 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 Arca Air Quality Management all new materials for inspection.
District?
❑Yes
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
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
rcg�tr�mcnts ichmytbe tpriortoissuancemr rcaeofot p - Signature of Applicant Date
hJ, -7 9 0 All roof coverings to be Class"B"or better
Owner or autorized age t I I Date