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08100149CITE' OF CUPERTINO BUILDING DIVISION PERMIT TolkiL®�p �q BUILDING ADDRESS: 10123 N OWNER's NAME: ARCHITEC IENGINEER: 0 o LICENSED CONTRACTOR'S DECLARATION U P 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing z w with Section 7000) of Division 3 of the Business and Professions Code, and my license is 7 y in full force and e f�ecy, yJ 5 ';�t� d -23 9 4 License Class �7 Lic. N q Dale �a'- 7�Contractor ARCHITECTS DECLARATION 1 understand my plans shall be used as public records yU C, ti Licensed Professional % y OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the :00 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 Z �y prior to its issuance, also requires the applicant for such permit to Ole a signed statement that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9 F $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or r3 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). ❑ I, 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 for sale (Sec. 7044, Business and Professions Code: The Contractor's 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.). ❑ I, 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 comtraclor(s) licensed pursuant to the Contractor's 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 Workces Compen- sation, as provided for by Section 3710 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: 2 Carrier. 7 Mei itU A)� Polity No.: 6 d % Z ✓— —�70 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Phis section need not be completed if the permit is forone hundred dollars ($110) or less.) 1 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 Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must C:) forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY a a I hereby affirm that there is a construction lending agency for the performance of Y4 > the work for which this permit is issued (Sec. 3097, Civ. C.) 4 Lender's Name . D Lender's Address J 0 1 certify that 1 have read this application and state that the above information is y� correct I agree to comply with all city and county ordinances and state laws relating to Dbuilding construction, and hereby authorize representatives of this city to enter upon the O above-mentioned property for inspection purposes. y (We) agree to save, indemnify and keep harmless the City of Cupertino against :o c/1 liabilities, judgments, costs and expenses which may in any way accrue against said City J 'Z in consequence of the granting of this permit. H APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOUR/CCE�AEG/UryA�TIiON 3 -108 i nawrc/I SofAppl t/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore or handle hayardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)9 ❑Yes XNo Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District? ❑Yes)LOU 1 have read the ha7arzaus materials requirements under Chapter 6.95 of the Califor- nia Health& Safety alifor- niaHealth&Safety Code, Sections_ 25505,25533 and25534.1 understand t_hatifthebuilding_ does not currently have a tenant, that it is my responsibility to notify the occupant of the u' cots -w eh- ust- m pror-lo-issuance-of- C��ificate�fOccupancy �nd1 i0 - 23 08 (Dw`ner of autho 'red agent Date ' 775)359-3131 Job Description INSTL (1) SET OF INTERN ILLUM. LTRS Ft, Floor Valuation APN Number Occupancy Type 31620100.FC7 Required Inspections Issued by: Re -roofs Type of Roof Date /0— All GJ'_ 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. All roof coverings to be Class'n" or better PERMIT NO. PERMIT ISSUE DATE A e 8 8 CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB Job Description INSTL (1) SET OF INTERN ILLUM. LTRS Ft, Floor Valuation APN Number Occupancy Type 31620100.FC7 Required Inspections Issued by: Re -roofs Type of Roof Date /0— All GJ'_ 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. All roof coverings to be Class'n" or better