06080087CITY OF CUFEKII,
BUILDING DIVISION
UIL.DING ADDI'.ESS:
OWNER'S NAME:
EVERSHINE
PHONE:
ARCHITECTIENGINEER:
PERMIT
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I hereby affirm that I am licensed under provisions oC Chapt1iccnn-
Dam
enchng
vith Section 7000) of Division 3 of the Business and Professionscense is
n full force and cffect,A`�
iccnsc Class ��!! Lic. #
Datc 1� CntractorARCHITECTS DECLA ATION
I understand my plans shall be used as public recordsLicensed ProfessionalOWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's Lfor thefollowing rcazon. (Section 7(131.5. Business and Profcmions Code:r countywhich requires a permit to conswct, alter, improve, demolish, or tructureprior to its issuance, also requires the applicant for such permit to fileagtatement
that he is licensed pursuant to the provisions of the Contractor's Lit -case 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 any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages az 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 docs 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,
howevu, Ube 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 projects with a contractor(s) licensed pursuant to the Contractor's
License Law. B & P C for this reason
❑ I am exempt under Sec.
nwner Date
WORKER'S COMPENSATION DECLARATION
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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 Worker's Compen-
uion, as provided for by Section 3700 of the Labor Code, for the performance of the
ork for which this permit is issued.
] I have and will maintain Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
7y Worker's Coppegsaton Insurancamer and Policy nuui arc:
:artier.,« V Policy No.: `� 3 �� •v�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic hundred dollars ($100)
rr less.)
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
-aws of California. Date
4pplicant
VOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
zecome subject to the Worker's Compensation provisions of the Labor Code. you must
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 (See. 3097, Civ. C.)
Lender's Namc
Lender's Address
I certify that I 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
SOUR[ EC ON 1 w
Signa of Appl' ' ontractor ! 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 ❑ No
Will the applicant or future building occupant use equipment or devices whitl
emit hazardous air contaminants as defined by the Bay Area Air Quality Managemen
District?
❑ Yes ❑ Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califon
nia Health & Safcty Codc, Scctons 25505, 25533 and 25534.1 understand that if the buildin
docs not,��urently have a tenant, that it is my responsibility to notify the occupant of th
rcuuiremenn ►.hick must be maborior to issuance of a Certificate of Occpparfy.
Owner or authorized
PERMIT NO. 0608008.7
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG] ELECT PLUMB
Job Description
T.I.-RETAIL UNISEX TOILET, GYPSUM BOARD
TBAR CEILING
Sq. Ft. Floor Area
36906008.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Awe
e
Occupancy
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
All roof coverings to be Class "B" or better
Date