09050151CITY OF CUPERTINO inlw ..... .
BUILDING DIVISION PERA41T
- ------------- -------
BUILDING ADDRESS:
10201 N DE ANZA BLVD FLR I XL CONSTRUCTI
OWNER'S NAME.
Cd Z
.0
Z
< C6F r 6
:)tn
Z1
ol
Date Contractor
9 IARcHr=S DECLUA%M4l lww
I understand my plans shall beused as public records
Licensoo ed Prfessinal
0 OWNER -BUILDER DECLARATION
I hcreby affirm that I ilm exempt from the Contractor's License Law for the
a 0 following reason. (Section 7031.5, Business and Professions Code- Any City or county
w which mquims a permit to consumct. alter. Improve, clemoNsh, or repair any structure
in prior to its issuance. also mquires ft applicant for such permit to rile a signcd statement
Z >_
that he is licensed pursuan ( to the provisions of the Conuwwej License Law (Chapter 9
that he is exempt th=from and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicam for a permit subiccis the applicant to a civil penalty Or
not more than five hundred dollm (S500).
owner or Lhe property, or my employets with wages 23 dwir Sole compensation,
wkcrU_ L-rd the smactwo is not intended or offerrd for sale (Sec. 70". Business
I MR w-►Mil FE N (i T" 9 1 lIlEt v�§ 51 K4.A-QIKN 11 VA 16m I xt IL-laO
�7
Fir U111LIJI!
5
L7L4l a3 L
however .6
builder wiU have the burden of proving that he did not build or improve for purpose o?l
sale.).
F1 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Col The Contractor's Li-
d
who contracts for such projects with a cDnLractor(s) licwwd pursuant to the Coniractor's
License Law.
1 am exempt under Sec. B & P C for this mason
Owner;
Date
WORKER'S COMPENSAT10N DECLARATION
I hemby alT= under penalty of pledury one of the following dedaradons:
sation.as provided for by Section 3700 of the Labor Code. for the performance of the
rk fm hich Lhis plamit is Li3ucd.
I hoe and will mainWn Worimes Compensation Insurance, as required by Section
y wcvkel, 2: "Irance caMer and Policy number am:
VA-2 I
Carries Policy No.:
CER71F) CATE OF EXEM MON FROM WORKERS
COMPENSATION INSURANCE
Misscztion need not becompleted if the permit is foronc hundred dollars ($100)
I ce Lh It in the performance of the work for which this permit is issued. I shall not
aT,% 7rP_1PF1T ET. 1`ry 1_1VWTTP_r &T
ii) AP�UCANT. If. after making this Certificate of Exemption, you should
become subj= to tbe Worker's Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
0
Z CONSTRUCTION LENDING AGENCY
H I h=by alTirm ihm there is -a construcfion lending agency ror the performance of
W4 > the work for which this permit is issued (Scc, 3097,
Lender's No
Z ARIPM00"H15—
U 0 1 certify that I have mad this application and state that the above informadon is
correct. I a8ree to comply with all city and county ordinances and state law% relating to
U building construction, and hcmby authori7z representatives of this c4y to enter upon the
abovt-mentioned property for inspection purposes.
(WO agree to save, indemnify and keep harmless: the City of Cupertino against
U— b411111 W--"
- ----------
Signature o A,ppRc9ht/C3n_trTctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or rulum building occupant score or handle hazardous m21M21
as dcTined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safcly
Code, Section 25532(a)?
0 Yes neo
Will the applicant or fuwrr- building occupant use equipment or devices which
cmil hazardous air contaminants as defined by the Bay Area Air Quality Management
DislLricO
M Yes
nus materials requirements under Chap ter 6.95 of the Califor-
I have mad the hazard,
tT
L doles not curren
AV
(408)271-2425
PERMI'T NO.
Q15-1—
PERM17 3SUE IDATE
or- lll!3c lll!3QIQQ
ANffAftU. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
COM I T—, T_T_ ELCTRCL CONNTN OF FURNITURE FRAME ON
BELOW GRID PARTITION W ALL
Floor Area
APN Number
-L2634070.FLR1 ro
Re -roofs
Type of Roof
gR PR
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.
Signature of Applicant Date
All roof coverings to be Class or better
----------------