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CITY OF CUPERTINO
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BUILDING DIVISION PERA UT
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BUILDING ADDRESS:
PERMIT NO.
20813 STEVENS CREEK BLVD
HALLMARK CONSTRUCTION INC
07070259
OWNER'S NAME:
PERMIT ISSUE DATE
STEVENS CREEK OFFICE CENTER AS
3360 DE LA CRUZ BL
PHONE:
SANrrARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
TI COMMERCIAL BUSINESS SPACE
BLDG ELECT PLUMB MF.CH
LICENSED CONTRACTOR'S DECLARATION
-. n_.-. Jab,Description
I hereby affirm that I ata licensed under previsions of Chapter 9 (commencing
-, -� - �--- - -. _,. _
with Section 7000) of Division 3 of the Business anti Professions Code, and my license is
in full fora and effect. _1 r
Llcenso.Class Lh.N i -)Z
.
DateContractor.1 A<`4-aA�t
ARCHITECTFC S DLAFCAT'fON�
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I bcmby affirm that 1 am exempt from the Contactors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to ctinsruet. alter, improve, demolish, or mpair any tirM:,T
prior to its issuance, also requires the applicant for such pefmit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to doe provisions of the Contractor's License Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
tha he is exempt therefrom and the basis for the alleged exemption. Any violat6 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 ($500).
I, 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 Proress(ona Coils The Contactors License Law does not. apply to an comer of
.
property who builds or improves thereon. and who does such wort himself or through his
own employees, provided that such improvements are sot 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 thathe did not build or improve for purpose M
sale.).
❑ 1. as owner of the property, am exclusively contracting with licensed contactors to
construct the project (Sec. 7044. Business and Professions Code-) The Contranmrs L3-
cc= Law don as apply to an owner of property .who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Comrrxars
License Law.
❑ 1 am exempt under See. , B & P C for this reason
Owner Dan
WORKER'S COMPENSATION DECLARATION
l hereby affirm under penalty of perjury one or the following declar*tiour
Q 1 lace and will maintain a certificate of Consent to self-hu im for Workers Compen-
sation. as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is issued.
Q 1 have and will maintain Workers Compensation Insurance, as required by Sation
3700 of the Labor Code, for the performance of the wort for which this permit is issr A
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My Workers Insurance carrier and Policy number are:
rCompensation
Carrier. U� WT7 Policy No.:30:1)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars ($100)
.
or less.)
I certify that its 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. Dan
AppBcamt
NOTICE TO APPLICANT: If, after making this Certificite of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this pernrft 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.)
Lsnders Name
Lenders Address
I certify that I have read this application and state that the above information is
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correct. 1 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, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Date l�rrf
SOUR REG AT1ONS.
Re -roofs
Type of Roof
SSgaature dApplicint/Conuactor Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicancOr mute building occupant Store or handle hmeardoos mateial
as defined by due Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Sawa 25532(a)7
All roofs shall be inspected to any roofing material being installed.
❑Yes WO
prior
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
cm1L hazardous air contaminants as defined by the Bay Arcs Air Quality Management
all new materials for inspection.
District?
❑ Yes 1�rNo
I have read the hazardous materials requirements under Chapter 6.95 of tit¢ Califor-
nia Health & Sarcty Code, Sections 25505, 25533 arul25534.1 understand that if the building
does not currently have a tenant. that it is my responsibility to notify the omrpant of the
mqut.swhic us be Met prior to issuance ofaCcnificaleofOccupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
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d er or authorv.¢agent
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