07010181CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
19091 PRUNERIDGE AVE
OWNER'S NAME:
HEWLETT-PACKARD COMPANY
PHONE:
SEAPORT BLVD
(650)216-3643
7
CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
CJ r=:J c:=:J CJ1az ~-----L-IC-E-N-S-E-D-C-O-NTR=-AC-=T:::'"O:::'"R:::'"'S=-D=-E=-C:::'"LA--:-::R:::'"A=:r:::'"IO:::'"N.,----------+-----------------J-b-D---.-'-.--==:!--.......="'-__...!==L. =d.._
; '" ~ I hereby amrm thaL I am licensed under provisions nf Chapler 9 (commencing 0 escnptIon ~~~ with Section 7(00) afDivision 3 of Ihe Business and Prafcssion,Cadc,andmy license is TI-SECURE OFFICE SPACE· NON STRUCTURAL-ATALLA
.::> '" in fuil faree and efffL (J . I 'I ~ 0\,,'1 1!a~ ;~~nsc~1_'dt ~~~~actart¥J,.olpli i 51",(06,. 1"'0 LAB-NO SANITARY REQUIREMENTS.
1!:; ~ ARCHITEcrS DECLARATION '
j ~~ I undcrSland my pl.lns shall be used as puhlic records
l"'U
: ~ fLicensed Professional :O~OWNER·BUILDER DECLARATION
I hcrchy affirm Lhal I am excmpl from the Conlrictor's License law for Lhc
,,,, ....
2:;: ::IE
.00 following reason. (Section 7031.S, Business and ProCessions Code: Any city or couruy
<~ ft whiCh requires a pennit to conslrUct. aller. improve. demolish. or repair any struc1ure.-",prior 10 ilS issuance. alsu requires the applicant for soeh permit 10 file a signed Slalement-:z >lhal he is licensed pursuant to lhe provisions of the Contractor's [jc"Cnse Law (Chapler9~id (commencing with Section 7(00) of Division 3 of lhe Bu'iness and Professions Ca~e) or ~~ :l that he is exempt t.hcrdrom and lhe basis for lhe alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjeclS the applicillltta. civil pen.lty of
t!-'"
nol more than five hundred dollars ($500).
f-------=---,=--;:;l;---:---------,----------,V:;-;"a"";l'u-a-t-;!.,...o-n---------Sq. Ft. F oor Area
$1 7 3 19 9 6
f----------;-=c:-:-::---:----------+---------::;------;:;;--------31607046.A.P N Number Occupancy Type
: iJ O'
o I. as owner of the property. or my employees with wages as lhcir sole compensation. \-----::---;-_--=-=-__--: _
will do the work. and the structure is nat intended or offered for sale (Sec. 7044, Business Required Inspecti 0 ns
and Professions Code: The Conlr3etor's License Law docs not apply to an owner of
propeny who builds orimproves lhereoR, and who does such work himself or through his
own employees. provided that such improvements are nOl inlended or offered for sale. If.
however. the building or improvement is sold wilhin one year of completion. the owner-
builder will have the burden of proving that he did not buiJd or improve for purpose of
sale.).
o I. as owrler of lhe propeny, am exclusively eonlracling wilh licensed conlraclors to
COnSll\lct Lhe project (Sec. 7044. Business and Professions Code:) The ConU'acwr's li
cense Law docs nm apply to an owner of propeny who builds or improves !.hereon. and .
who conU'acts far such projects with a contractor(s) licensed pursuanlto the Contractor's
License Law. o I am exempt under Sec.. , B & PC for this reason
Owner --;-__-====--;-=",-....". Date .,...-_
WORKER'S COMPENSATION DECLARATION
I bereby affirm under penally of peljury one of the fallowing declarations:
o I ha ...e and will maintain a Certificate of Consenl to self-insure for Worker's Compcn~
salion. as provided for by Section 3700 of lhe Labor Code, (or lhc performance of the
work for which this pennil is issued.
o I have and wiU maintain Workers Compensation Insurance, as required by Section
3700 of lhe Labor Code. for the performance of the work: for which Lhis pennit is issued.
My Worker's Compensation In~urance tarrier and ~r"~lr arc:
Carrier:Wi",1. ~-..... I'l$U'=YNa.: ,AtG.1'fC,53lJ7o"]
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhis section need rlOl he eomplelCd if the permit is for one hundred dollars (SIOO)
or less.)
I ecnify th~1 in the pcrfonnance of the work for which this permit is is.c;ued. I shall not
employ any person in any manner so as to become subjecllo the Workers' Compensation
Laws of California. Date _
Applic.nl ...,,----,-_---,-__,----_-,..,._---,-_
NOTICE TO APPUCANT: If, afler m.king this Certificate of Exemplian. yao sbaold
become subject to the Worker's Compensation proVisions of the Lahor Codc. you must
fonhwiLh comply wilh such provisions or Lhis pcrmilshall be deerned revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Lhat there is a conslrUction lending agency for Lhe pcrfonmmcc of
lhe work for which this pennil is issued (Sec. 3097 I Civ. C.)
Lender's Name .
Lender's Add",ss _
I certify lhat I have read this application and state lhal Lhe above information is
eorrecl. l agree Lo comply with all cily and county ordinances and slate laws relating \0
bUilding construction. and hereby authori7e representatives of !.his city to enter \lpon the
aho'Ye-memiom;d property for inspection purposes.
(We) agree 10 save, indemnify and keep harmless the Ci\y of Cupertino against
liabilities. judgments. costs and expenses which may in any way accrue against said City
in consequence of the granling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON·POINT
SOURCER
Si alure f Applican on ctor Date
HAZARDOUS MATERJALS DISCLOSURE
Willlhe applicant or fUlun: bUilding occupant store or handle ha:r.ardous material
as defined by the Cupertino Monicipal Code. Ch.pler 9.12. and the Health .nd Safety
Code, Section ;15532(a)1 ,.",co
DYes C'"u
Will the applicanl or fUlure building occupanl usc equipment or devices which
emil hazardous air contaminanLS as defined by Lhe Bay Area Air Quality Management
District?
DYes 'tJNO
I have read lhe ha7..ard()u~rials requirements underChilptcr 6.95 of Ihe Califor
nia Health & SafelyCadc,Sections 25505,25533 and 25534.I ondcrslOnd thaI if the building
docs nO( currently have a tenant, lhal it is my responsihilily (0 notify (he occupant (If the
rcquircmcn . must . issuance of a Certificate of Occupancy.
-r.n
D.lIe·
Issued by: Date
Re-roofs
Type of Roof
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 "B" or better