07060030 77777777777777-777 77777.:1:;::
CITY OF CUPERTINO
BUILDING DIVISION PERMITCINF }I �TON:
PERMIT NO.
BUILDING ftTS WY VENTURE BUILDERS 07060030
l PERMIT ISSUE DATE
OWNER'S NAME:
EMBARCADERO CAPITAL PARTNERS 1509 INDUSTRIAL RD 06/05/2007
SANITARY NO. CONTROL NO.
,NE:
(650) 59E�-3999
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0 0
O p LICENSED CONTRACTOR'S DECLARATION Job Description
UP i hereby affirm that I am licensed under provisions of Chapter 9(commencing
z� with Section 7000)of Division 3 of the Business and Professions Code,and my license is I NTER I O F: DEMO OF OFFICE SPACE ON 2 FLOORS
<> in full force and effect �1
License CONTRACr'OR NEEDS TO RENEW BL
��Z lC au ConlraMof� I
t—o Datc� /. ✓ilZ t
ARCHITECTS DECLARATION
J a< I understand my plans shall be used as public records
)yV
U.H Licensed Professional
< OWNER-BUILDER DECLARATION
a1 hereby alThrm that I am exempt from the Contractor's License Law for the
:p O 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
"H prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S q.Ft.Floor Area $159980
t= (commencing with Section 7000)of Division 3 of the Business and Professions Code)ur
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 of3 572 0 04,-ABV Number Occupancy Type
not more than five hundred dollars(5500).
0 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 Required Inspections
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.).
0 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 contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec .B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
0 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 Workees Compensation Insurance carrier and Policy number are:
Carrier:�"fA r� kU pJ Policy No.:f0/6 0cr6 2��
CERTIFICATE F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 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,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 Ezcmption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
HCn 1 hereby affirm that there is a construction lending agency for the performance of
tx> the work for which this permit is issued(See 3097,Civ.C.)
W Q Lender's Name
0 Lender's Address
U Q I certify that I have read this application and state that the above information is
Iy correct.I agree to comply with all city and county ordinances and state laws relating to
J building construction.and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (Wc)a rce to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,j mcnts,casts and ezpcnscs which may in any way accrue against said City
(�2 in copse .or the granting of this per 'l. Date
►-h APPLI UNDERS DS AND ILL COMPLY WITH ALL ON-POINT Issued by:
SOU REGUL
SD Re-roofs
Sign re of Applicant/Contractor Dam Type Of R Sof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cotk,Section 25532(a)? All roofs,hall be inspected prior to any roofing material being installed.
0 Yes
Will the applicant or future building occupant use equipment or devices which
If a roof i:,installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new In iterials for inspection.
District?
Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 anil 534.1 understand that if the building
docs not cu pity have a tenant,that it is my res nsihilily to notify the occupant of the
require which must b.m r to isse ofa certirtt:ate of ate, cy Signature of Applicant Date
d All roof coverings to be Class"B"or better
wn or authorized agent Date