08100066CITY OF CUPERTINO
CO;Rr; I1\F,Q��
BUILDING DIVISION PERMIT
1�tiOR
BUILDING ADDRESS:
PEeMR NO.
4 INFINITE LOOP
SAN JOSE CONST
'
ER'S NAME:
DT P !`(�A�DiTTI: D1210
C121-RMAN AWS
PERMIT ISSUE DATE
PHONE:
SAIQrfA CONTROL NO.
(408)986-8711
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG SECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
- IOU DOSCTIptIOn
1 hereby affirm Nal l am licensed under provision of Chapter 9 (commencing
with section 7000) of Division 3 of the Business and Professions Cade, and my license is
in full torte and cffcLO
TI—CONVERT (E) STORAGE ROOM TO SERVER R, 001-'.
License class Lle.x
Date Con nteserDEL_TA_ ^
INCLDS
ON
RCNRECI'S DECLA ATION
tun raranJ yplansshilibcusedupubliemcoda
NEW A/C EQUPMNT, NEW ELCTRCL DISTRB & INTER WALLS
REV #08110090
Licensed Pmressi... I
OWNER-BUILDER DECLARATION
I hereby afrifm that I am exempt from the Cmuraoor. License Law for the
following maW n. (section 701.5, BLLtlnea{ and profession Code: Any city of county
which rnquia perenil to construct, aIle,, improve. demolish, or repair any uruzum,
rn
prior to its Issuance. also fcquirs the applicant for such Permit to rile a signed sutemmt
Sq. Ft. Floor Area
Valuation
that he is licensed p... Intothe provision of the Conlracmfi License Law (Chapter 9
(commencing withSection 7000) of Division 3 of the Business and Professions Code) or
3 O O O O 0
that be is exempt therefrom and the basis for the alleged exemption. Any violadon of
APN Number
Occupancy Type
Scedm 703 L5 by any applicant fora permit subiccla the applicanud a civil penally of
not mom dun Esc hundred dollar ($500).
31602108 .04
❑ I, u owner of the properly, or my employees with wages sat their sale compensation,
Required Inspections
will do the work, and the shuclum is not intended or offered for sale (Sec. 7014, Businw
and Pmfessians Code The Contractors License Law does not apply to an owner of
property who builds or improws themon, and whodossuch work himself ser through his
own employees. proHded Nal men improvements am not inmused oroffefed for We IL
hawser, the building or improvement is sold within one year of oompleuun. the owner-
builder will have the burden of proving that the did not build or improve for purpose of
sale.).
❑ I. as, owner of the properrY• w exclusively conrrcdng with licensed "ou"welma to
construct use, project (Sce. 7044. Business and Professions Code:) The GentraCmrs V.
cone Law does not apply In sn ower, of property who builds ars improws Mentor. and,
who contracts for such projects with a cnno-a:mr(s) licensed pursuant m the C.Mrsenea
License Law.
❑ 1 am sempt under Sec . B & P C for this maven
Date
WORKER'S COMPENSATION DECLARATION
1 hereby a?rto under Penalty of perjury, one of the following declarations:
❑ I have and will maintain a CeniOwm of Consent m self-iuum for Workers Compen-
sabon, as provided for by Section 3700 of the IaW, Code, for dm perfunnance of tho
work for which this permit is issued.
Q 1 have and will maintain Workers Compensation Insurance, as mquired by Section
3700 of the Labor Cade, for Ne Performance of the work for which this permit u issued.
'
My Workers Compensation IAaurm. artier apd Policy number am:
"Alley 3
No.; AM
Caner:�RT
IUTE OFVEMMONKO
COMPENSATION INSURANCE
(This section need not carnplemd if vte pcmtil is for one hundred dollars IS 100)
or less)
I ser ifv, Not in the performance of the work for which this permit is wood. I shall not
employ, ant' person in any manner as u to brconse subject sa the Woken Cumpenution
Laws of Califomia. Date
Applinnt
NOTICE TO APPLICANT: If, afer making this Certificate of Exemption, you should
become subject to the Workers Compensation previsions of the Labor Cade, you most
' forthwith comply with such Provisions or this Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 herby ilffm Nat mart is s convection lending agency for One parfufmanec of
este wan for which this permit is iunea (sea. Jlrn, ay. ea
'
Lenders Name
,
Inmdcra Adala4
I mrofy that 1 hale mad this application soul t u Ne ahow infomtation is
' coneel. I agme m comply with ill tity and comfy oudinocea and sum laws relating m
Wilding consvuction, and kmby authorise mpfsenu ,eros of Nis city In enmr upon the
sh m.cr endoned property for inspection purpoaes
(WC) agree to sale, indemnify and keep harmless the City of Cupertino against
i liabilities Judgments. casts and expcnss which may in any nay seems, against said City
A cPLIC NT of the DERS"EANDSng Of this per mit.
' APPLICANT UN'DERhTANOS AND WILL COMPLY WITH ALL NON-POINT
ISSUed by: Date (� I
SOURCEULATION�
Date
HAZARDOUS MATERIALS DISCLOSU REType
of Roof
Will the applicant or future building oCcupmt store or handle hnardous mamrial
as defined by drc Cupertino Municipal Cods,, Chapter 1, 11, and the Health and Safety
c. Section 25333(a)?1:1 V4.o
Yes
All roofs shall be inspected prior to any roofing material being installedV.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
emit hazardous air contaminants defined by me Bay Area Air Quality Management
all new materials for inspection.
Distri '?
Ya u
I hew real Ne huaN.vs mamrials'5Timmense miler Chapterd.95 of meCalifor-
niaHanth&Salmy Cade,Secdmu 35505, 25577 ara135531.IuMcrstald dwirtM Wilding
does net Currently have a mnam. that it is DIY MoMelbility to notify the occupant of Ns,
myaimmc
m