08120027 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � ��Ckr
BUILDING ADDRESS: PERMIT NO.
10435 N TANTAU__AVF NOVO CONSTRUCTION 081 2,()n27
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
650) 701-1500
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
u0C LICENSED CONTRACTOR'S DECLARATION Job Description
v I herebyaffirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of that
3 of the Business and Prof n Code,and my license is
'may in full force and effect- 1022 COMM'L TI REMDL INTERIOR W/ONE SRVER ROOM
z License Lie.if
n�,o Datc Contractor t+
W ARCHITECTS DEC ON
3 l understand my plans shall be used as public records
�yU
14 i<n Licensed Professional
0..l OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
a 9 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
xthat he is licensed pursuant to the provisions of the Contractor's Licenac Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or 8250000
y 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 five hundred dollars(5500). 31606039 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the stmctum is not intended or offered for sale(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 themon,and who dues such wort himself or through his
own employees,provided that such improvements am 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.).
❑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 does not apply to an owner of property who builds or improves themon,and.
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑I am exempt under See. B&P C for this reason
Owner Dam
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 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 War s Com nation huu a�-rry.er and Policy number am: q
Carrier.VC' �'\C-1,'j 1-L`�01'try No.: 0 �U
CERTIFICATE OF EXEMPTION FROM VIO RKERS'
COMPENSATION INSURANCE
(This 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.1 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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z""' CONSTRUCTION LENDING AGENCY
. I hereby affirm that there is a constructian lending agency for the performance of
Ix 5 the work for which this permit is issued(See.3097,Civ.C.)
W A Lender's Name
Z Lendees Address
V O 1 certify that 1 have mad 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 concoction,and hereby authorize representatives of this city m enter upon the
0 U
W a ntioned property for inspection purposes
G4 c)ag to save,indemnify and keep harmless the City of Cupertino against
rA )abiliti judg cn costs and expenses which may in y way ucmc against said City � �v
V in cone uenc of granting of this permit Date
APPLI U ERSTANDS AND WILL O Y ITH ALL NO -POINT Issued by:
SOU TIONS.
R 0 Re-roofs
Sign um of AppliclitylContractlO D're T of Roof
H OUS MA ALS Dl URE Type
Will the applicant or future building occupant s handle hazardous material
as defined by the Cupertino Municipal odc.Chapter ,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes a
f is installedw'thout first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as elefinc the Bay Area Air Quality Management all aterials for spection.
District?
❑Yes _
qOwnc4or
mad ardour materials requirements under Chapter 6.95 of the Califor• (� i
afi ty ,Sections 25505.25533 and 25534.1 understand that if the building l O
e y ve a tenant that it is n)bila notify the occupant or the
must be met prior to' C fiats of S gnatu Of pp' a t D to
horir agent Dam roof coverings to be Class" "or better