07030017CITY OF CUPEK-L'INU
BUILDING DIVISION PERMIT NT
BUILDING ADDRESS:
10123 N WOLFE RD
OWNER'S NAME:
CUPERTINO SQUARE LLC
PHONE:
ARCHITEC (ENGINEER:
10o Zp LICENSED CONTRACTOR'S DECLARATION
3 U i=. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
: Z w with Section 7000) of Division 3 of the Business and Professions Code, and my license is
s < a in full force and effect.
j Z License Class Lic. H
F„ vOi Date Contractor
ARCHITECTS DECLARATION
i a < 1 understand my plans shall be used as public records
>yU
U. y Licensed Professional
= h OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
`e,�, PL which requires a permit to construct. alter, improve, demolish, or repair any structure
u — rn prior to its issuance, also requires the applicant for such permit to file a signed statement
• ? G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
'.x
at— (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
L .. 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 (3500).
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 forsale (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.).
P,f.'as owner of the property, am exclusively contracting with licensed contractors to
tonstroct 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 Contractor's
License Law.
1 am exempee� , B RC, r this o_n_
Owner ' Date
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I hereby affirm under penalty of perjury one of the following.declarations:°
❑ I have and will maintain a Certificate of Consent to self -insure for Workers 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.
My Workers 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 ($100)
or less.)
1 certify That in
provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building eonswction, and hereby authorre representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs d expe *s which may in any way accrue against said City
in conseq �
Signature of Applicant/Contractor Dare
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hayardous material
as defined by the Cupertino Muni ' Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
[:1 Yes QNo
Will the applicant or future bu' ng occupant use equipment or devices which
emit hazardous air contaminants cfhned by the Bay Area Air Quality Management
District?
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & SalelyCode, Sections 2550$„ 25533 and 25534.1 understand that if the b ilding
does not cu tl have a n t. at 7 s my responsibility to notify th occup of the
rcyuircm
,i n,i,.
PERMIT NO.
TBD — TO BE DETERMINED 07030016
PERMIT L55UE DATE
SANITARY NO. CONTROL NO,
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
TEMP PERMIT FOR EAST SITE IMPROVEMENT —ORIGINAL
PERMIT #05060075 EXPIRED 04/05/07
Ft. Floor Area
$0
3 162 0 0 3 7 qP Number
Required Inspections
Issued by.
Re -roofs
Type of Roof
on
Occupancy Type
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 r'B'r or better