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081200980z zC �W+ � wJ Z UC u. F t1 UZ r CITY OF CUPERTINO BUILDING DIVISION PERMIT0� ��� BUILDING ADDRESS: PERMIT NO. 20830 STEVENSREEK BLVD NORTHWEST SIGNS OR12009S OWNER'S NAME: By PERMIT ISSUE DATE -PHONE- A CONTROL NO. (831)469-8208 ARCHrrEC "GINEER: BUILDING PERMITINFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provWoms of Chapter 9 (commencing with ofDivialon3ofthe Business and Profession Code. urdmylicense lsin run foe110 C .tom Lk. r INSTL 4'X20' ILLUMINTD LETTER SET READNG Lkensa Class Date Contractor r ,"STAPLES" ARCH I IFCI S DPr s •ltaTiON I understand my Plana shall be used as public records Licensed Professional OWNER-BUIIJ)F-R DECLARATION 1 hereby affirm that 1 am exempt from the Contractors Lkrnse Law for the 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 prior to its issuance. also requires the applicant for such permit to file a signed statement UM he Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 70D0) of Division 3 of the Business and Professions Code) or 5 0 0 0 that he is exempt therefrom and the basis for the alleged exemption. Any violation or 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 (SS001 35908027 .00 ❑ 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 for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner or property who builds or improves thereon and who does such work himself or through his we employem provided that such improvements are not interaled oroQered 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 exciuuvely contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The coatraetors Li- cense Law does not apply to an owner of property who builds or impruves thereon, and , who contracts for such projects with a contranor(s) licensed pnasuant to the Contractor's License Law. ❑ 1 am exempt under Sec , B A P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby a[Ilna under penalty of perjury arc of the following declarations ❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workers Compcn- sation, as provided for by Section 3700 of due Labor Code, for the performance of the wort for which this permit is issued ❑ 1 haw and will maintain Workers 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 Imsuran�ce,canie/gaud Policy number am: Cartier. &eWr-e5 L / V't I ,r-s Policy No.:�Z CERTIFICATE OF EXEMFTION FROM WORKERS' COMPENSATION INSURANCE (This section reed not be campkred lithe permit Is for one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit Ls issued, 1 shall not employ any person in any marmer 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 ibis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a cons ruction Lending agency for die performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Lenders Address I certify that I have read this application and state that the above information is correct 1 agree to comply with all city and county ordinancces and state laws relating to building construction, and hereby authorise representatives of this city to enter upon the above -mentioned property for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and experscs which may In any way accrue against said City in eonsequercc of the granting of ibis permit APPLIcANT UNDERSTANDS AND WILL COMPLY WITH A11. NON -POINT Issued by: Date SO REGULATIONS. /V./PGZ& Co Re -roofs Type of Roof Signature of pplianUConiractor HAZARDOUS MATERLkLS DISCLOSURE Will the applicant or future building occupant state or handle hazardous material as defined by the Cupertino Municipal Code. Chapter 9.1 Z and the Health and Safety Code, Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑ Yes 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 Use Bay Aura Air Quality Management all new materials for inspection. District? ❑ Yes I have read the hnardous materials requimmonta under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections25505, 25533 and 25534-1 understand that irthe building does not currently have a levant. that It is my responsibility to notify the occupant of the requkAnts which must be met 'or to issuance of a Ccnificaic of occupancy. ignature of Applicant Date / All roof coverings to be Class in" or better Da Owner o(a orirr•dagcnt