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CITY OF CUPERTINO
G 1NTE C 'iiR IN ° ;RMATI_N� '
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19638 STEVENS CREEK BLVD
TBD TO BE DETERMINED
PERMIT NO.
07010051
PERMIT ISSUE DATE
CCR DEVELOPMENT
03/15/2007
PnONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
SUITE: 230/260 — TI
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 a 0
LICENSED CONTRACTOR'S DECLARATION
D4 UIN
o escnp ion
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
- - - --^ - -- - - - ---- ^-- ^
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effecL
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
License Law (Chapter 9
that he is licensed pursuant to the provisions of the Contractor's
(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
APN 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,
Required Inspections
q P
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 docs 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.).,,,
owner of the property, am exclusively contracting licensed contractors to
construct the project (Sec. 7044, Business and Prolessio Code:) The Contractor's U.
cense Law does not apply to an owner of property w ilds or improves thereon, and
who contracts for such projects with a contractoft I 1 ed pursuant to the Contractor's
License Law. : -/.
❑ I am exempt under Sec,_ B & P C ribis reason
ER -S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declamations:
- -
I have and will maintain a Certificate of Consent to self -insure for Workces Compcn-
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 Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy 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. I shall not
employ any person mono o to bc�rnyvIt ,e }o the Workers' Compensation
Laws of Califor9ra Da /i� L
AppliCartc ^,
NOTICE TO APPLICANT: If, after"ing dRi4ai0'ficatc of Exemption, you should
become subject to the, orki r`s Compensation provisions of the Labor Code, you must
forthwith eomply4j�jih Stich 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 i& issued (Sec. 3097, Civ. C.)
~ Lender's Name
Lender's Address
7
I certify that I have read this application and state that the above information is
Corect. I agree to comply with all city and county ordinances and state laws relating to
~ building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
1, (We) agree to save, indemnify and keep harmless the ay of Cupertino against
on liabilities, judgments, costs and expenses which may in any way accrue against said City
7 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POT
Issued b y Date f'
Re -roofs
Type c f Roof
SOURCE REGULATIONS
:. ---'s� %
Signature of Applicant/Conjractor ' ^-T arc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicanr6i future building occupantstorc or handle hazardous material
defined by the Cupertino Municipal Cpdc, Chapter 9.12, and the Health and Safety
'c, Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
[3 Yes o
If a ro )f is installed without first obtaining an inspection, I agree to remove
Will the applicant or future bwlding cupant use equipment or devices which
emit hazardous air contaminants as deli. by the Bay Arca Air Quality Management
all nes r materials for inspection.
District?
Cl Yes o
f
I have read the hazardous materials rcquircmcnisundcr Chaptcr 6.95 of dtc Califor•
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenanL.thatft is my responsibility to notify the occupant of the
Date
requircmcrup which must be met prior to issuance of a Certificate of Occu ey. /
Signat ire of Applicant
.... `= S
All roof coverings to be Class "B" or better
Owner or authoriz% agcol- are