06100023 CITY OF CUPERTINO
BUILDING DIVISION �-+'� ��'"�����\�"�� s
PERMIT
BUILDING ADDRESS: PERMIT NO-
BUILDING06100023
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
1 O p LICENSED CONTRACTOR'S DECLARATION Job Description
U P I hereby affirm that I am licensed under provisions of Chapter 9(commencing
.Z M with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�a-
in full force andcffect- T. I . -MOVE 2 INTERIOR DEMISING WALLS (NON STRUCT
)_? LicenseC
Clazs onlraclor d AND 2 INTERIOR DOORS
t„•,w Date o
,,•t ARCHITECTS DECLARATION
C< t understand my plans shall be used as public records
>yU
in Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
L in O 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
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valu,*M 0 0 0
cx
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 for sale(Sec.7044,Business Required Inspections
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,
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.).
❑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-
ccase Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for siLch projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑lam exempt oder Se. B&P C for this
Owner Date
WO KER'S COMPENSATION DECLARATIO
I hereby linn under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 Polity number are:
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 that in the fortnance of the work for which this permit is issued.I shall not
employ any person i any ncr so az to become subject to the Workers Compensation
Laws of Cali(oro' . m
Applicant
NOTICE TO APPLI A :If,after making this Certificate of Exemption,you should
become subject to thd Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z r CONSTRUCTION LENDING AGENCY
Fr►�. I hereby affirm that there is a construction lending agency for the performance of
a, the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Lender's Address
U 0 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
O building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
Rr (We)agree to save,indemnify and keep harmless the City of Cupertino against
r�r liabilities,judgments,casts and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
►� APPLICANT NDE STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE RE ONS.
O Re-roofs
Signature of A licam/Contractor Date
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 shall be inspected prior to any roofing material being installed.
❑Yes <No
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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materirlls for inspection.
District?
❑Yes Yl No
1 have read the hazardous
materials requirements under Chaptcr 6.95 of the Califor-
niaHealth&SafctyCodc,Sections 25505.25533 and 25534.1 understand that if the building — "—`► '0 1
docs not current) have a tenant,that it is my responsibility to notify the occupant of the
requirements why' It muip be met prior to issuance of a Certificate of Occupancy. Signature f Applicant Date
AO, , r All roof coverings to be Class"B"or better
Owner or authori.cd c Date