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CITY OF CUPERTINO
PERMIT
Cfi� T'Rr TO ��OIZM�TI�N• '.
BUILDING DIVISION
BUILj?I);1�TIR TEVENS CREEK BLVD
1 `� / U
TBD - TO BE DETERMINED
PERMIT NO.
07090172
OWNER'S NAME:
PERMTr ISSUE DATE
KCR DEVELOPMENT
09/25/2007
SANITARY NO. CONTROL NO.
jNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
DEMO OF (E) C ONDT I ONS ( NON- BEARNG INTER WALLS,
in full force and effect.
Lic.B
DRS, IN'iER WNDWS, TOILET CORE, DEILNG & MEP
License Class
Date ARCHITECTS DECLARATION Contractor
INFRAST.RCT
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's 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
Sq Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Contractor's License (Chapter
$10000
(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
3690600 8 Number
Occupancy Type
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to in owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder wiy have the burden of proving that he did not build or improve for purpose of
sale.).
as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractors) ' d pursuant to the Contractor's
License Law.
❑ 1 am ere esSe B & P C for this
Owner DateN71�r�Z
WORK ON DECLARATION
-
I hereby affirm undo aeaity of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workeescompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars ($I00)
or less.)
I certifv that in the performance of the work for which this permit is issued, 1 stall not
employ any person in any m to c?m;.i jest to the Workers' Compensation
Laws of California ate
Applicant
NOTICE TO APPLICAlWafter making this Certificate of Exemption, you should
become subject to the Wo is Compensation provisions of the Labor Code, you must
7 forthwith comply with such provisions or this permit shall be deemed revoked.
j
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.)
atender's Name
Lender's Address
I certify that I have read this application and sate 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 authorize representatives of ibis 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
Z in consequence of the granting of this permit.
—+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
?r
Issued b): Date l�7
SOURULATIONS.
--�—.��
Re -roofs
T of Roof
Type
Signature of Applicant/Contrac Date
US MATERIALS DISCLOSURE
Will the applicant or future building occupantstorc or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cotte, Section 25532(a)?
All shall be inspected prior to any roofing material being installed.
Yes
roofs
❑
a roof is installed without first obtaining an inspection, I agree to remove
ll the applicant or future building occupant use equipment or devices which
Will
emit hazardous air contaminants as d cd by the Bay Arca Air Quality Management
all new materials for inspection.
District?
C3 Yes u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 undersand that if the building
docs not currently have a tenan4 dual it my responsibility to notify the occupant of the
Date
requirements w ' h must be. m issuance of a Certificate of Occupancy.
Signaturc of Applicant
e --a
All roof coverings to be Class "B" or better
OwnerC"uthori-zed agc ate