070100787Y OF C;Urrnludv
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19630 STEVENS CREEK BLVD
01"NER'S NAME:
EVERSHINE
PHONE:
ARCHITECT/ENGINEER:
00
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PERMIT NO.
TBD — TO BE DETERMINED 107010078
PERMIT ISSUE DATE
I hereby affirm that I am licensed on provisions of Chapter 9 (commencing
rith Section 7000) of Division 3 of the Business and Professions Code, and my license is
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full force and ct. Lie # C//)
censc
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Sam Contractor
M7 CPS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I 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 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 Weir 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 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.).
❑ 1, as owner of the property, am exclusively conuacting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:)Tim 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. B & P C for this reason
❑ I am exempt under Sea
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
REVISION: CALCS FOR SECURITY VAULT
ORIGINAL PERMIT: 06090010
Sq Ft. Floor Area
36906009't Number
Date
WORKER'S COMPENSATION DECLARATION
f 11 'n declarations
I hereby affirm under penalty of pepury one of the o owr g
❑ 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 tabor Code, for the performance of the
work for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy nuum are -
Carrier:` ` �"� {wthLY� Policy No.: Vl/{ 5 %r�i1�f YrI1
C RTIFICATE 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 arm r subject to the Workeri Compensation
Laws of California. Date
Applicant
NOTICE TO C : If, after making this Certificate of Exemption, you should
become subject to the orkcr's Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permif�s jFsucd (Sec. 3097, Civ. C.)
Lender's Namc �A
Lender's Addre<-'r
Icertify that I have read this application and state that the above information is
co1 agree to comply with all city and county ordinances and state laws relating to
burrect.ilding construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cos nd expenses which may in any way accrue against said City
in consequence of the g ting of this permit.
APPLICANT UNDER ANDS AND WILL COMPL ITH ALL NON -POINT
SOURCE REGULA S.
Da
Signature of Applicant/ omractor
H DOUS MATERIALS DISCLOSURE
Will the apptic t or future building occupant store or handle hazardous material
as defined by the Cu vino Municipal Code. Chapter 9.12, and the Health and Safety
-4c, Section 25532(a)7
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District?
❑ Yes ❑ No
1 have read the hamnit s materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sec ons 25505, 25533 and 25534.1 understand that if the building
does not currently have a to nt, at it is my responsim rior toissu of a Csctificate of Oc'cnup�'c�ybility to notify the occupant of the
requirements wh"st
Owner or
Issued by:
Re -roofs
Type of R:)Of
Valuation
$500000
Occupancy Type
Required Inspections
All roofs ;hall be inspected prior to any roofing material being installed.
If a roof i; installed without first obtaining an inspection, I agree to remove
all new rr aterials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better