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BUILDING DIVISION
aulLgll��oEs TEVE
PERMIT
S CREEK BLVD
OWNER'S NAME:
KCR DEVELOPMENT
NE:
ARCHr'ECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 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 effect.
License Gass Lic. #
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I 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
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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 arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
0 I, as owner of the property, or my employees with wages as their sole compensation,
will do the work. and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon. and,
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Caw.
0 lam exjepmptuqoda SEC- B& P C or this
Owner ml
\\ VAA y f� Date o
� WoRRBR'S COMPENSMIDN BECLARKrION
I hereby affirm under penalty of perjury one of the following declarations
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I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
3710 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ 100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any so be dsubject to the Workers' Compensation
Laws of CalifoIQ
Applicant
NOTICE TOAPPLICANT.- If, after making this ctu l cafe of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you trust
forthwith comply with such 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 is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. 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.
(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
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici al Cock. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
O Yes o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
0 Yes{fi�
I 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
dais not currently have a tenant, that it is my responsibility to notify the occupant of the
rc uirQcmcn�which must ;metp
1 rior to issuance of a Certificate of cup,,r� , � I W`f�lrTA\IY7J(/1Y/!�1 am
-30
Owner or authorized agent Date
PERMIT NO:
TBD - TO BE DETERMINED 07050189
PERMIT ISSUE DATE
05/30/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
MECH
Job Description
REVISION -STATUE BASE-ORIG PERMIT #06120168 NO NEW
PERMIT. ALCA Bf.;ILDERS NEEDS A BL.
;iq. Ft. Floor Area
36906003
Issued by
Re -roofs
Type of Roof
$0
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof i; 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 "B" or better