08090166y00
i
n<c,
Dwd
� W
5a
N
�p0aea
V � y
—z�
CITY OF CUPERTINO
PERAUT
r ass
BUILDING DIVISION
BUILDING ADDRESS:
PERMrr NO.
OWNER'S NAME:
PERbfrr ISUE DATE
PHO
S CONTROL NO.
ARCHIIECT/ENGINEER
BUILDING PERMrrINFO
T.I—STAPLES—DEMO INTERIOR—
BLDG ELECT PLUMB MECH
o 0 0
LICENSED CONTRACTOR'S DECLARATION
REMOVAL Job Description
I bereby sffirm 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
ifull
l force and eff
u IJc.
Dale Contractor
ARCHrrECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alTirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city err county
which requires a permit to construct alter, improve, dcmollah, or repair any structure
- —
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Fl Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
oor
(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 exempdor Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
Cl L as owner of the property, or my employees with wages as their join compensation,
Required Inspections
will do the work, and the structwe is not intended or ofkred for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law don not apply to an owner of
propcny who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such impmvemunu are not intended or offered for sale. If,
hor-cm, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did rot build or improve for purpose of
sal.).
❑ L as owner of the property, am exclusively contracting with Ednsed contractors to
construct the project (Sec 70". Business and Professions Coda:) The Contractor's U.
cease Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
IJcense Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
,
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain aCertifiate of Consent to self -Insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workces Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
'
My Worker's r-PCompensation Lance carrier and Policy number am
D'I + `$
Carrier. +' � F Policy No.: TT
T
CERTIFICATE OF EXEMFr1ON FROM WORKERS'
COMPENSATION INSURANCE
(This section wed col be completed if the permit is for once hundred dollars (SI00)
or Icss,)
I certify that in 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 Worker! CDmpenutian
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 or
the work for which this permit is issued (Sec. 3097, Civ, C.)
Lender's Name
,
Lender's Address
I certify that I have read this application and stale 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 authorize representatives of this city to enter upon the
abme-mentioned property for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against
liabilities, judgments, coats and expenses which may in any way accrue agalast said City
in consequence Of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUI�EGULATIONS.
DW
��VS."'.�•
1A'�,
Re -roofs
Type of Roof
Signature of A'179 'arts/ onttactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aaupant. store or handle hazardous material
as defined by the Cupertino Munici Code. Chapter 9.12. and the Health and Safety
Cc&.Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
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 h"Ardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
DiuricO
❑Yes [�No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant, that It is my responsibility to notify the occupant of the
ens which must" t poor to tssuar -,. of a Certificate Of Occupancy.
Signature of Applicant Date
roof coverings to be Class'%" or better
Owner or as Drircd a�g�cnt DateAll