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08110014Z ad 200 z i 3E -w �$'yv �yU L p, l-- �0< �W.4 �CO YF❑ 0z Z� CITY OF CUPERTINO BUILDING DIVISION PERIVIIT�RAQ��#Tl�� TT BUILDING ADDRESS: PERMIT NO. 10201 TORRE AVE TBD - TO BE DETERMINED OWNER'S NAME: PERMIT ISSUE DATE PHONE: S A CONTROL NO. ARCHrrECr/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000) ofDivi n 3 of the Business and Professions Code, and my license is in full force and effect. SS14U COMM' L TI; EXTERIOR DOORS (REPLACE GLASS & DOORS) License Class Lic. q '51 Date Contractor tLto GAS ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, 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 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Cade)ser that he is exempt therefrom and the basis for dee alleged exemption. Any violation of $15080 APN Number Occupancy Type p y yp Section 70315 by any applicant for a permit subjects the applicant to a Civil penalty of not more than five hundred dollars ($500). 36941005 .MP ❑ p petty, or my employees with wages as their sole compensation, I, as owner of property, Required Inspections will do the work, and dee structure is not intended or offered for sale (Sec. 7044, Business and Professions code: The Contractors License Law does not apply to an owner of _ property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, dee building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and . who contracts for such projects with a coniractor(s) licensed pursuant to dee Contractors License Law. ❑ I am exempt under Set , B & P C far this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of elm following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -insure for workers Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the of the work for which this is issued n performance permit My Work in Policy number am: in e� //� Ac �.a7y►�Parl'/ qo gfrr¢ orre� 1 �l Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' O Z v Q COMPENSATION INSURANCE V C� o (This section need not be completed if the perm it is for one hundred dollars ($ 100) or Irst) 1 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 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCr1ON LENDING AGENCY I 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.) - Lender's Name " Lenders Address 1 certify that I have read this application and state that the above information is ' correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes (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 � in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCEREGU HAZAS MATERIALS DISCLOSURE Will the applicant um building occupant store or handle hazardous material as defined by dee Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section25532(a)? All roofs shall be inspected to any roofing being installed. []Yeso prior material If a roof is installed without 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 def] d by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes u 1 have mad 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 currently have a tenant. that it is my responsibility to notify the occupant of the requirements which m met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date Y} All roof coverings to be Class " '' or better Owner uthorizcd agent Date