07010093BUILDING DIVISION
BUILDING ADDRESS:
OWNER'S NAME:
BAY 18 LLC
ARCHITECT/ENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
dth Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full forte and effect
.icense Class Lie, i
)atc conlractur
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
-icensed Prufcssional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
'allowing reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to concoct, alter, improve, demolish, or repair any structure
mrior to its issuance, also requires the applicant far such permit to file a signed statement
hat 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
hat he is exempt therefrom and the basis for the alleged exemption. Any violation of
iecdon 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
iot more than five hundred dollars ($500).
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.).
W. 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 contractor(s) licensed pursuant to the Contractors
License Law.
❑ i am exempt under Sec�.(� '� / , B & P C for this reason
Owner J 7 r'' �..J�- .f'' Date 1 I 7r< 7
WORKER'S COMPENSA ONI N DECLARATION
I hereby affirm under penalty of perjury ane 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 Workers Compensation Insurance carrier and Policy number are:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis 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. I shall not
employ any person in any manner so as to become sub cl tm the Workers' Compensation
Laws of Califo ' "a FaIST� T .�'L(c+T—
Applica I t— 1 ✓t H
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.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work fur which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that I have read this application and state that the above information is
cored. I agree to comply with all city and county ordinances and state laws relating to
building concoction, and hereby authorize representatives of this city to enter upon the
above-menticned 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. _
_
Date
HAZARDOUS MATERIALS DISCLOSURE
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)?
❑Yes ONo
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?
❑ Yes C;No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code, Sections 25505.25533 and 25534. I understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which be met prior to issuance of a Certificate of Occupancy.
Owner or authorized anent V ri—r
PERMIT NO.
01/17/
SANITARY NO.
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
TI: SUNSHINE ACCUPUNCTURE HEALTH SPA- NEW OFFICE
TREATMENT RMS. ADA BATH/SHOWER RM
Sq. Ft. Floor Area
32609061:
Issued by:
Re -roofs
Type -of Roof
Valuation
$48000
Occupancy Type
Required Inspections
Date
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 "B" or better