07030018 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C�1TRI�CTQR �vRMTr�
BUILDING ADDRESS: PERMIT NO.
10123 N WOLFE RD TBD — TD BE DETERMINED 07030018
OWNER'S NAME: PERMIT ISSUE DATE
CUPERTINO SQUARE LLC 03/05/2007
.ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
t:z with Section 7000)of Division 3 of ahe Business and Professions Cade,and my license is LOWER LEVEL CEILING PATCH BACK REPAIR IN 3 SPOTS.
?"e y in full force and effect
r n i License Class Lic.#
-F-,m Date Contractor
ARCHITECTS DECLARATION
i a< I understand my plans shall he used as public records
>yV
U.ti Licensed Professional
0,
OWNER-BUILDER DECLARATION
<f 1 hereby affirm that 1 am exempt from the Contractor's LicenseLaw for the
in Oa following reason.(Section 7031.5,Business and Professions Code:Any city or county
Ii which requires a permit to construct,alter,improve,demolish,or repair any structure
Z yy prior to its issuance,also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
uH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5000
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 ofN umber Occupancy Type
not more than rive hundred dollars(5500). 3162003
❑I,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 for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
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 Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and•
who contracts for such p 'c with a contractor(s)licensed pursuant to the Contractor's
License Law
❑lam ex _teeSe B&P C r ' reason
Owner Date
-WORKER'S COMPENSATION DECLARATIO
hereby affirm under penalty of perjury one of the following declarations:
�]I 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 formic hundred dollars($100)
or less.)
I cerdfv that in the odWorman o work/6r whichthis pc it' j I not
employ any perso m ncr o c subject to sation
Laws of Califo
Applicant
NOTICE T0%PkJCAIlft.If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z"" CONSTRUCTION LENDING AGENCY
[~- 1 hereby affirm that there is a construction lending agency for the performance of
(yi> the work for which this permit is issued(Sec.3097,Civ.C.)
ALender's Name
z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
w ►-'
correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to s&indc .nifykeep harmless the City of Cupertino against
1conc
mcnts, hich may in any way accrue against said City
U Z of the it.
UN EILL COMPLY WITH ALL NON- INT Issued by: DateU
Re-roofs
icanUContractor arc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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
Code.Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes CfN.
Will the applicant or future building occupant use equipment or devices which
If a roof i;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes /
1 have read the hazardous materials requirements under Chap 6.95 of the Califor-
nia Health&Safety Code,Sections 2550,2553 d 25534.I undcrs d if the building
docs not cu tl have a to t i is my nsibility to no I' occupant of the
requireme a mat rior aCertirg Signature of Applicant Date
Owner e a a agent , a� A11 roof coverings to be Class "B"or better