07030286CITY OF CUFERI11NU
BUILDING DIVISION PERMIT Ii1AOR:
ZQ sT�,
PERMIT NO.
BUILT10355EN DE ANZA BLVD SOUTH BA`..r CONSTRUCTION CO 07030286
PERMIT ISSUE DATE
BR'S NAME:
APPLE 170 KNOWLES DRIVE, STE 120 03/27/2007
SANITARY NO. CONTROL NO.
PHONE:
(4 08) 379--5500
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Divi.' n 3 of the Business and Professions Code, and my license is
in full force and effect. 7
License CI Lic. i
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License 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
that he is licensed pursuant to the provisions of the Contractor's License Law (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 (5500).
❑ I, 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 Contractors 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.).
❑ 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 Contractors
r nse law.
in exempt under Sec. B & P C for this reason
t —caner Date
t WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one 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 the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have 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 Workeees Com enation Insurance carrier and Policy number are:
Cartier. fe 4A Policy No.. b–�,j(�� —I I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc 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 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.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a consuuctinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
L.cnder's Address
I certify that 1 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
building construction, and hereby authorise representatives of this city to enter upon the
ahovc-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in con nee f the granting of this permit.
APP Irnnrr DERSTANDS AND OMPLY WITH ALL NQN-POINT
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
fined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
..de, Section 25532(a)?
❑ Yes f®No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants defined by the Bay Area Air Quality Management
District?
❑ Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Section 25505.255 3 and 25534. I understand that if the building
docs n fly have a tenan4 drat it is responsibility to no
the occupant of the
rcqu' menta wh' h must be met u once oC a Certificate of �-
Owner or authori-zcd agent Date
Job Description
ADD 8 OF:�'ICES & DOORS. NEW PAINT, ELECTRICAL &
HVAC.
sq. Ft. Floor Area $110000 Valuation
32633113 . Number Occupancy Type
,,Required Inspections
Issued by:
Re -roofs
Type of R(,of
Date 3— Z 7'`7
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 maerials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better