07020126 CITY OF CUPERTINO � I�tFRMTIN:
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: TBD — TO BE DETERMINED 0 7 0 2 012 6
10268 BANDLEY DR #106
�— PERMIT ISSUE DATE
�OvNER'S NAME:
03/12/2007
3ANDLEY CENTER SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
(�
Z LICENSED CONTRACTOR'S DECLARATION Job Description
a I hereby affirm that I am limned under provisions of Chapter 9(commencing
with Section 70(X))of Division 3 of the Business and Professions Code,and my license is TENANT IMPROVEMENT—INTERIOR WALL NON STRUCTURAL
y in full force and effect.
Z License Class Lte•A
p Date Contractor
ARCHITECTS DECLARATION
xa
I understand my plans shall be used as public records
yU
L H Licensed Professional
o a OWNER-BUILDER DECLARATION
y, I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7(l3 L5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation
y prior to its issuance,also requires the applicant for such permit to file a signed statement Sq.Ft. Floor Area $18000
?a that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9
F (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 Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 32633097
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation, Required Inspections
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 contracting with licensed contractors to
contract the project(Sec.7044,Business and Profession Code:)The Contractor's Li-
rty who
s or improves
n.and
who c contracts for sucLaw does not h projectsywith a c nan owner of tractor(s)licensed dpursu pursuant to the Contractor's
License Law. B&P C for this mason
❑1 am exempt under See
nu 3
WORKE C PEN TIOND RADTIONN4�
I hereby affirm under penalty of ury one of the following declarations:
❑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 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 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,l shall not
employ any person in any maartcr as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,of making th' Ccrtifi c of Exemption,you should
become subject to the Worker's C pensation visions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
-
(�Cn I hereby affirm that there is a construction lending agency for the performance of
fx> the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
0 Lender's Address
I certify that i have read this application and start that the above information is
U� correct.I agree to comply with all city and county ordinances and state laws relating to
E" Building construction,and hereby authorise representatives of this city to enter upon the
Wabout-menuoncd property for inspection purposes. (\\`
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accrue against said City
U Zin consequence of the granting of this permit. (' Date
�. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: x
SOURCE R ULATiONS.
••t Z � Re-roofs
Signature of A licant/Con for Da Type of Roof
HAZAR OUS MA RIALS DISCLOSURE YP
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
'ode,Section 25532(a)? \ / All roofs shall be inspected prior to any roofing material being installed.
❑Yes If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which all new materials for inspection.
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? lg(/
❑Yes u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the Date
rcquircmc which must be me prior w issuance of a Certificateliul,
pancr. Signature of Applicant
All roof coverings to be Class"B"or better
Owner ora orizcd agent ate