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080900363E o )LOU r U. y �] a m 3Z` clxSlS-''p Ly�^ CITY OF CUPERTINO DIVISION pERNUT n + L�LY T iR� s C1�L�r BUILDING J�t1 ` .. .. r .,,.fit :.:r ..:.?'•" ,,,. BUILDING ADDRESS: PERMIT NO. 10215 S DE ANZA BLVD TBD — TO BE DETERMINED 08090036 OWNER'S NAME: PERMIT ISSUE DATE PHONE: A - CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70(10) of Division3 of the Business and ProfessionsCode, and liurtse is in full force T.I. INTERIOR REMODEL OF SALES AREA F04 (E) RADIO and effect. l / License Class LIC. 0 Date Contractor %t SHACK. TTECI S DECLARATTO 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following mason. (Section 703 1.5, 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 rile a signed statement Contractors Llccrise Law (Chapter 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 6 O O O 0 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of not more Watt five hundred dollars WWI. 35910060 .00 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections ee will do the work• and the structure is not Intended or offered for We (See. 7044, Business taw donot apply to an owner of and Professions Code: The Contractors License n q P property who builds or improves We rcon, and who does such work himself or through his own employers, 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 Contractors Li- 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 Contractors License Law. ❑ I 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 Workers Compen- sation, as provided for by Section 3700 of the tabor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Worket'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 Workers Compensation Insurance carrier and Policy number are: ? Carrier./%1? - aLe ! �L' i Policy No.: a)E !_I S — %GI - l ERTI & PITON FROM WORKERS' COMPENSATION INSURANCE (Ibis section need not be completed if the permit is formic hundred dollars ($100) or less) I unify that 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 Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I 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.) ' Lenders Namc Lender's Address 1 certify that I have read this application and state that the above information is corren. I agree to comply with all city and county ordinances and state laws relating to building construction. and hereby aulhorbic representatives of this city to enter upon the ahove-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, toss and expenses h may in any way accrue against said City in consequence of the granting of this p IL APPLICANT UNDEjtSTANDS A WILL COMPLY WITH ALL NON -POINT n �1 Issued by: Date L s0 CER TIONS, Re -roofs - Type of Roof 1 4 naturc o pm) cam/Contractor Date 7t 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)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yrs ❑ No 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 emit hiaardnus air contaminants as defimcd by the Bay Area Ali Quality Management all new materials for inspection. District? ❑ Ycs ❑ Nu I have read the harrials requi s under Chapter 6.95 of the Califor- nia Health& Safety Code, 05, 25533 534. f understand that if the building docs not ntly hJeit is m risibility to notify the occupant of the requich ora certificate of Occupancy. Signature of Applicant Date 12 -4n All roof coverings to be Class 'A ' or better DWEG Owner or aut mi7ed aVnl I .