07010027 CITY OF CUPERTINO
BUILDING DIVISION PERMITR IRM�TIf�N.
' PERMIT NO.
BUILDING ADORE
10624 S DE ANZA BLVD NIELSEI\'/AIRE CORP 07010027
SS:
PERMIT ISSUE DATE
OWNER'S NAME:
3YER PROPERTIES 1601 GI.LVEZ AVE
SANITARY NO. CONTROL NO.
WJE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MEC14
TI .CONII�[ERCIAL RETAIL STORE— 0 0
I p p LICENSED CONTRACTOR'S DECLARATIONPARTTT]011 o Description
:m r- 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing --^- —- —-•-^ —^--^ ^'^ '
_,U with Section 7000)of Div�r=' Business and f ions ,a my license is
r a in full(once and effectIng
j ? License Class •it
Date . Conrado
S DECL.ARAT
i C a 1 understand my plans shall be used as public records
)yU
U.y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
a m 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 c'q•Ft.Floor Area Valuation
-?< that he is licensed pursuant to the provisions of the Contractur's Liccnsc Law(Chapter 9
aF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
L that he is exempt therefrom and the basic for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500).
Q 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors 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.
Q 1 am exempt under Seo. B&P C for this reason
^-•ner Date _
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations.* -
❑I have and will maintain a Certificate of Consent to self-insure far 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.
❑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.
Ca Workers Comperr�sort In' r ca of o.:number are: —
Cartier. OJ J No.:
CERTIFICATE OF 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,1 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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 A Lender's Name
Lender's Address
U C I certify that I have read this application and state that the above information is
IL correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
r�raliabilities' cn an xpe • which may in anyway accrue against said City
Vl
U Z in c quence the g n'ng thi it. Date 3 i Cr
LI ANT DE T N COMPLY WITH ALL NON-POINT Issued by.
OURCE REG A
Re-roofs
Signatu pplian on for ateT of F.00f
HAZARDOUS MATERIALS DISCLOSURE Type
Wil the applicant or future building occupant store or handle hazardous material
as defined y e Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
^,,Ic,seed 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Q Yes 2N/o
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
C]Yes No
I have read the h ous materials requirements under Chapter 6.95 of the Califor.
nia Health&Saf Se tions 25533 and 25534.1 understand that if the building
J
ly ha a th r is my responsibility to notify the occupant of the
re uiremcn is st to mance of a Certificate of Occupan . Signature of Applicant Date
`6 All roof coverings to be Class"B or better
Owner authonxed agent Date