07080233CITY OF CUPERTIlVU
BUILDING DIVISION PERMIT
PERMIT NO.
BUIL I G
��9nTEVENS CREEK BLVD J & J AIR CONDITIONING 07080233
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NER'S NAME: P£RMrrISSUE DATE
STEVENS CREEK OFFICE CENTER 1083 N 11TH ST 09/05/2007
,,-&.r. SANITARY No. CONTROL NO.
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ARCHITECIYENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licenced under provisions of chapter 9 (commencing
Pith Section 7000) or Division 3 of the Business and Professions coda, and my license is
n full force and effect. L-7— a
_icensc Classar�t � OL3r� Lia. # 5—_&52J '7,
3atcLi-�-� Contractori A
ARCHITECTS DECLARATION
I understand my plans shall he used a:; public records
_icenscd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
;allowing reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to cnnstruct, alter, improve, demolish, or repair any structure
priarto its issuance, also requires the applicant for such permit to file a signed statement
[hat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commcacing 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).
❑ t, 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 forsale (Sec. 7044, Business
and Professions Code: The Contractors 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.).
fZ 1, as Owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec, 7044, Business and Professions Code:) The Contractors U -
cense Law docs not 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 Contractor's
Licence Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby afrtrm under penalty of perjury one of the following declarations:
❑ I have and will maintain aCertificate or Consent to self-insare for Worker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 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 Policy number am:
Carrier. 6&001-�14'r Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(-this section need not he completed if the permit is for one hundred dollars ($100)
or less.)
I certify diet in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workcrs' Compensation
Laws of California Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate or 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 decmed rriOked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a eonstructinn lending agency for the performance of
.the work for which this permit is issued (Sec, 3097, Civ- C.)
Lender's Name
. LErtdes Address
1 certify, that 1 have read this application and sum that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hamhy autborim mpresanlalives of this city to enter upon the
above-mentioned property for inspection purposes,
(Wc) agree to satire, 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
071gnature of ApplicantlContraclor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Coda, Section 25532(a)?
Cl Yes _X No
Will the applicant or future building occupant use equipment at devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes J4 No
I have read the hazardous ma[crials requirements under Chap[cr695 of the Califor-
nia Health & Safely Cade, Sccuons 25505.25533 and 35534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notily the occupant Of the
require nus whic must be met prior to issuance ora Certificate of Occupancy.
9 -s -G
(408)920-0662
BUILDING PERMIT INFO
BLDG ELECT PLUMB
0
Job Description
REPLACING HVAC ON COMMERICAL BUILDING OFFICE
J e Je_
Sq, Ft. Floor Area
32632053 .W Number
Issued by:
Re -roofs
Type of Roof
$80250
Required Inspections
Occupancy
Date
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