06100024 CITY OF CUPERTINO
BUILDING DIVISION PERMITT �TaR I1t�}RM 'IQ `
BUILDING ADDRESS: PERMIT NO.0 6 10 0 0 2 4
10883 N WOLFE RD
PERMIT ISSUE DATE
OWNER'S NAME:
VISION FIRST 10/04/2006
E. SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: 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
?Z with Section 70(X))of Division 3 of the Business and Professions Code,and my license is
�y in full force andrffecL TI- MOVE EXISTING ENTRANCE DOORS FROM SOUTH
z License Class Con
Date Conr<tractor FACING TO EAST FACE
ARCHITECT'S DECLARATION
,a
U 1 understand my plans shall be used as public records
O in Licensed Professional
�a� OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
OO following reason.(Section 7031.5,Business and Professions Code:Any city or county
<$ii which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuati$i2 0 0 0
_ that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area
r t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i $ 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 APN Number Occupancy Type
not more than rive hundred dollars($500). 31605053 . 00
❑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 forsale(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 employers,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(wild or improve for purpose of
sale.).
❑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 contractor(s)licensed pursuant to the Contractor's
License Law.
C3I am exempt u er Sec B&P C for this reason
Owner Date
OR I R5 COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
U 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 arc:
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 thatin th performance of the work for which this permit is issued,I shall not
employ any perso in any manner so az to become subject to the Workers'Compensation
Laws of Califo ZLa
Applicant
NOTICE TO APPC NT:If,after making this Certificate of Exemption,you should
become subject to he Worker's Compensation provisions of the Labor Code,you must
,J Q forthwith comply with such provisions or this permit shall be deemed revoked.
z omV CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(Y, the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
2 z Lender's Address
U 0 I certify that I have read this application and state that the above information is
(L" correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned 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 Z in consequence of the granting of this permit.
h" APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
S4��t�zw
SOURCE RE AT NS.
Re-roofs
Signature of A Iicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ANo
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.ait hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �/lu
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 curren y have a tenant,that it is my responsibility to notify the occupant of the
requirements hm be met prior to issuance of a certificate ofDeen ancy. Signature of Applicant Date
Owner or auth 'zees ages DateAll roof coverings to be Class"B"or better