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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
10123 N WOLFE RD
DPR CONSTRUCTION INC
07020104
OWNER'sNAME:
PERMIT ISSUE DATE
CUPERTINO SQUARE LLC
1450 VETERANS BLV
03/01/2007
PHONE:
SANITARY NO. CONTROL NO.
(650)474-1450
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of DivWon 3 of th Business and Professions Code, and my license's
REVISION • STRUCTURAL CLARIFICATIONS
nd in full force ameffect
License Class Lk. s
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
.
i hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Carle: 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
dust he is licensed to the of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
$ 9 9 9 9 9 9 9
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
OCCu anC
p y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars (55 I
31620037 .`�(�
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the wort. and the structure it not intended or offered for sale (Sec. 7044. Business
and Professions Code: Contractors License Law does not apply to an owner o!
eThe q
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 Conuactoes Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contnctor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION`"---
i hereby affirm under penalty of perjury one of the following declarations
_
❑ 1 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the wort 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 (EI00)
or less)
,
I certify that in the performance of the work for which this permit is issued. I 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 Workers Compensation provisions of the Labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
i 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-)
iLender's Name
,
Lender's Address
I certify that 1 have read this application and state that the above informatiun is
t corecL I agree to comply with all city and unty ordinances and state laws relating to
building construction. and hereby thor' pr lives of this city to enter upon the
ahovc-mentioned property for i cti
(We) agree to save, i c nir a p armless the City of Cupertino against
i liabilities, judgmcm, costs n hi may In any way accrue against said City
in consequence of the ti of '
t APPLICANT UN ST D D L COMPLY WITH ALL NON -POINT
Issued by: Date
I
SOURCE REG 0
Re -roofs
Type of Roof
pli Con ctor Date
SignatuZz
OUS MATERIALS DISCLOSURE
applicant r future building occupant store or bandit hazardous material
as defined by the Cupertino Municipal Code. Chapter 9,12, and titre Health and Safety
Code, Section25532(a)7
❑ Yes
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
Will the applicant or uturc building occupant tax equipment or rkviccs which
emit harardnus air contaminants as defined by the Bay Area Air Quality Managcmcnt
all new materials for inspection.
District?
❑ Yes
1havere ar.0 mate Is requirements under Chapter 6.95ofthe Cali(or-
niaHcalth&S yC - ons 5,25533and25534.lundcrstandthatifthebuilding
does i
not cu rat y ant tit is my responsibility notify a oceupant of the
rcyuircmcn whi u me riortoissuanceo(aCcrtor
Signature Applicant Date
/ J J
of
All roof coverings to be Class "B" or better
Owner
'boric a c Date