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CITY OF CUPERTINU
BUILDING DIVISION PERMIT�Tl►R1�r
BUILDING ADDR
10400
OWNER'S NAME:
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(IW) of Division 3 of the Businessand Cessions Code, and my license is
in full force and effect
License CI Lle• M
Date Contractor
ARCHrrECTSDECLARA
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors 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 any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars (S500).
❑ 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 Contractors 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. U.
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 Contractors Li-
cense Law does not apply to an owner of property who builds or improves themon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Set B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation, as provided for by Section 3700 of the labor Code, for the performance of the
wait for which Nis permit is issued.
❑ I have and will maintain Workers 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 Commusatio Insurance artier and Policy numr e
Grier t icy No.: _
CE TIFI ATE 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 subject to the Workers' Compensation
Laws of California. Date
Applicant
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 for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and sate that the above information is
correct I agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned propeny for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, coats and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT =ERSTIAN AND WILL MPLY WITH ALL NON -POINT
SOURCE
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)? f
❑ Yes N ryo
Will the applicant or future building occupant use equipment or devices which
Omit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes 0<0
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health k SafctyCodc, Sections 25505.25533 and 25534.1 understand that if the building
does not currently
Date
408)991-10
PERMIT NO.
n09010094
PERMIT ISSUE DATE
S A CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
COML TI INSTL 2 NEW MOD
SHLDRMS,MECH&ELECT,SIESMIC
ANCHRG;894SQ—NO RE—RF & YES—STRUCTURL
Sq. Ft. Floor Area Valuation
25000
APN Number Occupancy Type
31606046.APL
Required Inspections
Issued by:
Re -roofs
Type of Roof
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". ' or better
Date