09010051 CITY OF CUPERTINO nn�n�
BUILDING DIVISION PEI pERMITNO.
BUILDING ADDRESS:
1505 S DE ANZA BLVD +INC
ENERAL �IGHTI pERMITISSUEDATE
OWNER'S NAME:
A O. CONTROL NO.
.hi0 E:
(408) 298-6670 BUILDING PERMIT INFO
MECH
ARCHITECT/ENGINEER,. BLDG ELECTC] PLUMB
G]
a reo C LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
i ui 0 with Section 7000)of Division 3 of the Business and Professions Code,and my license is REV I S I OT : RE-LOCATE PG&E TRANSFORMER
Cy in full force and effec Lie. �y�0 ��7
License ass ORIGINAIi# 08090033
Date Contractor
CHrrECTS DECLARATION
< I understand my ins shall be used as public records
�yU
1',O H Licensed Professional
OWNER-BUILDER DECLARATION
N 3 I hereby affirm that I am exempt from the Contractor's License Law for the
go O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct,alter•improve'dcmolish,or repair any structure Valuation
4;0 prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q' 3 5 0 0 0
x F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or Occupancy Type
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 AP Number
not more than five hundred dollars($500). 3 6 61 012.L . 01
❑1,as owner of the property,or my employees with wages as their sole compensation, Required Inspections
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 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.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.).
Cl 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 U'
cense Law s not Apply to an owner of
roves thereon.and.
who contracts for property
or such projects with coniractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under SeB&P C for this reason
Sec.
Date
Owner
WORKER'S COMPFIJSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I as and will maintain a Certificate of Consent to self-insure Cor Workees Compen-
sation,az provi led for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 Of the;:!;;Code.Car the performance of the work for which this permit is issued.
My Wor��OGF
tice carrier and Policy numberare: �/
Cartier. Policy No.:g7(EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thon need not be completed if the permit is for one hundred dollars(S 100)
or less)
I certify the performance of the work for which this permit is issued,I shall not
employ ann in any manner so as to become subject to the Workers'Compensation
Laws of Ca.Date
Applicant
NOTICE TPLICANT.If,after making this Certificate of Exemption,You should
become suo the Worker's Compensation provisions of the Labor Code,you must
'Z, forthwith with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
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 QLender's Name
]z Lender's Address
I certify that I have read this application and state that the above information is
LUL" correct.I agree to comply with all city and county ordinances and state laws relating to
O V 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 CityCn Date `l
in consequence of the grating of this permit.
U Z APDL NT UNDERSTANDS AND LL COMPLY WITH ALL NON-POINT Issued by:
S E GU O —
�d Re-roomscan
for D8Ic Type of�ROof
h ° HAZARDOUS MATERIALS DISCLOSURE YPe
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.
C3 Yes , If a roc f is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which all new materials for inspection.
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes XNo
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
dees no urenty have a tenant,that it is my responsibility to notify the occupant of the Date
s ch must be me fm trance of a CcrtiOcatc of Occupancy. Signature ire Of Applicant
All roof coverings to be Class'"or better
Datc
t cd a t
'