07060252BUILDING DIVISION
BUILDING ADDRESS:
10440 BUBB RD
OWNER'S NAME:
MISSION WEST PROP
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Z O CONSTRUCTION LENDING AGENCY
E~" ►�- 1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lender's Name
Z Lender's Address
U O 1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
rJ U building construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for ins pectionurposes.
Q. (Wclserce to save, i t y and harmless the City of Cupertino against
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ARCHITECTIENGINEER:
PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business androfesst�Codc, and m license is
in full force and effect 2i/�2
License Clasp Lia M
Date Contractor
AR HMCT"S DECLAR T N
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 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
which requires a peril 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
that he is licensed pursuant to the provisions of the Contractor's License taw (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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).
❑ 1, 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 trot 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-
ccnse Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
Q 1 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:
t I I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3701 of the Labor Code, for the performance of the
work for which this permit is issued.
0 1 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 Workers Compensation Ins�me carrier and Polity number tis:
Carrier: oliry No.:
ER. FICATE F E) 3MPTION FROM W RKERS'
COMPENS TION INSURANCE
(flus section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workcrs 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
forthwith comply with such provisions or this permit shall be deemed revoked.
liabiliti ju mcnts, atndcxpenscs
in c q c C gra t'i o[ this pc
PLIC DERSTANDS AND
may in any way accrue against said City
COMPLY WITH
Si at p ttcontractor f I C Date /
AZARDOUS MATERIALS D[SCL URE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municip ode. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as cd by the Bay Area Air Quality Management
District?
❑ Yes Nu
1 have 5a the hazardu na quirements under Chapter 6.95 of the Califor-
nia Health & Si y cc tions 25505. 5533 and 25534. l un nand that if the building
docs not cuirm ly ant that it)d my responsibility notify thcfccccupant of the
rcuuimmEnis us( mel prio issuance of a e_' cam oC V :cy.
Owner
MCLARNE': CONSTRUCTION
4082468E00
PERMIT NO.
07060252
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
Job Description
ORIG. PERMIT # 07050079 TEMPORARY PERMIT*** NO
INSPECTIONS UNTIL ASBESTOS ABATEMENT
REPORT/CLEARANCE
sq. Ft. Floor Area valuation
N $200
35720036 .0 V Number Occupancy Type
Required Inspections
Issued by:
Re -roofs
Type of R )of
All roofs :,hall 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 m iterials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better