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CITE' OF CUPERTINO
BUILDING DIVISION PERIVII I
C�RCTOR IR�Io'N'
BUILDING ADDRESS:
PERMIT NO.
10600 N DE ANZA BLVDBRAT
OWNER'S NAME:
PERMIT ISSUE DATE
PHO tT2 �T�n
A7
A CONTROL NO.
(408)973-1500
ARCHI7'EiCr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB . MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7IX10) of Division 3 of the Business and Professions Code nd my license is
in lull force and effect. '
COMM' L TI 2 5 0 0 SQ DEMO OF INTER NON- STRCTRL WALLS
License -Class Lk. t! n )-5)
Date Contractor Cbv�l v
NEW PRTNS & NEW LIGHT FIXTURS
' ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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which requires a permit to construc4 alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cock) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
$150000
APN Number
Occupancy Type .
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
31602103.250
C:] 1, 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 forsalc (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 nes 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
constructt 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
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who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Date
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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 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 Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
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My Worker's Compensation Insurance carrier and Policy num bbcrr�are:
LI)9�/l7PolicyNo.: 0LP2•-1��-I
Carrier.1?4LT C- �P
WORKERS'
CERTIFICATE OF EXEMPTION FRO_0
COMPENSATION INSURANCE
,
(This section need not he completed if the permit is Cor ane hundred dollars (5100)
or less.)
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 Workers' Compensadon
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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 I-abor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the wort: for which this permit is issued (Sec. 3097, Civ. Q
Lender's Name
Lender's Address
I I certify that I have read this application and state that the above information is
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correct. I 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
ahovc-rricndoned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,jes udgmenls, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICAI T UNDEI NDS AND WILL COMPLY WITH ALL NON- OINT
`.
Issued by: Date r "( -a -
SOURC�GUL23 fP
p-'� L� /
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Re -roofs
Signatur o�licant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chaptcr 9.12, and the Health and Safety
Cork, Section 25532(a)?
❑Yes o
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
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
all new materials for inspection.
District?
1-1 Yes
I have read the hazardouuss_materials mquimmcnis under Chapter6.95 of the Califor-
_ nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand thatif die building_
does not currently have a Icnant. that it is my responsibility to notify the occu ant of the
quirernen -which-Tri -!S r prior-to-issuance-ora-Cerificate.o Occuan
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Signature -of -Applicant Date
t
All roof coverings to be Class'j�`' or better
Date '
wner oaulhori.cdagent C
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