07080191CITY OF CUPERTINO
BUILDING DIVISION PERMIT
OWNER'S NAME:
APPLE
PHONE:
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ARCH17ECTIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
ALIT Section 7000) of Division 3 of the Business and Professions Code, and.my license is
n full fore and effe
.icanwAlass Lic. g v eeh� T
3we —� Contracto L'-
ARCHITECTS DECLAAAMOOJ
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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 (3500).
❑ 1, as owner of the property, or my employees with wages as thew sole compensation,
will do the work, and the st<-ucture is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
properly who builds orimproves thereon, and who doessuch 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 Contractor's Li-
cense Law does not apply to an owner of property .who builds or improves thereon, and
who contracts for such projects with a cons actors) licensed pursuant to the Contractor's
License Law.
❑ 1 am 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:
❑ 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 Polity ere am: � 3
Carrier:P4Q t-:G 11�C.LA; A i, No.:
I CERTIFICATE OF EXEMpIMN FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person rn mar�q�� so ecq�o-bject to the Workers' Compensation
Laws of calitorn D `� —
Applicant
NOTICE TO APP CAM: If. after making this Certificate of Exemption, you should
become subject to the Workcr's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the wurk for which this permit is issued (Sm. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorise 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,judgmems, cos d expenses which may in any way accrue against said City
in consequ of the gra in of it.
APPLICA DERS S
Applican tractor Date
HAZARDOUS MATERIALS DISCLOSURE
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)?
❑ Yes o
Will the applicant or firuturcbuilding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ yes
Nu
I have read a azard, smate' s uimmants under Chapter6.95oftheCalifor-
nia Health & Safat
Co , Sections 2 05 3 d 25534.1 understand thatif the building
does not currentl h
upan
Owner or authorized agent Date
SAN JOSE CONSTRUCTION
1210 COLEMAN AVE
(408)986-8711
PERMIT NO.
07080191
PERMIT ISSUE DATE
09/19/2007
SANITARY NO. CONTROL NO,
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
T.I. 2ND FLR E/M/P INCLUDES LIGHTING NON
STRUCTURAL OFFICE SPACE.
Sq. Ft. Floor Area
32 633108AgbT Number
Issued by:
Re -roofs
Type of Roof
$310000 Valuation
Required Inspections
Date
Type
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 Date
. All roof coverings to be Class "B" or better