09030076CITY OF CUPERTINO
BUILDING DIVISION PERMIT
1.{EIIA'
BUILDING ADDRESS:
PERMIT NO.
20525 MARIANI AVE
SOUTH BAY CON
OWNER'S NAME:
INC
PERMr Lb-UE DATE
PHONE:
S A CONTROL NO.
(408)379-5500
ARCHTIEC IENGINEER:
BUILDING PEPMrrINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700r1) or Di lion 3 of the Business and Professions Code, and my license is
infun form derrect. "?36
INSTL NEW 9 ' H STORFRNT INTER GLAS/ALUM SYS
oto�c' coon-
;
W/6@X7@
ARCHTf DC TS DEC.AR; 7
1 understand my plans shall be used as public records
DBL STOREFRONT DOR
Licensed Proressional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exampt from the Contactors License Law for the
following reason. (Section 70313, Business and Prorrssions 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 Seedon 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exeroption Any violation of
9 5 0 0
APN Number
Occupancy e
Pane Y TyP
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (shoo).
3 2 6 5 6 0 0 1 .001
❑ I, as owner or 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 Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such wort himself or through his
awn 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 buvdcu or proving that he did not build or improve for purpose of
salt.).
El 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Coatractor's Li.
cerue Law does not apply to an owner of property who builds or improves thereon, snd ,
who contracts for such projects with a contracmr(s) licensed pursuant to the ConVacta is
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
-
❑ 1 have and will maintain a Certificate of Consent to self -insure 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 Workers Compemsation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
'
My Wor ompensadon Insurance carrier and Policy number a1:
Carrier. �Polity No.�� O 45(tg 3 }---9
C CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
CPhis secdon need not be completed if ibe permit Is for one hundred dollar (S I00)
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 Compensatlon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exempdon, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peanit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that theft: is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C-)
Lender's Name
Lender's Address
1 autify that 1 have read this application and state that the above information is
cored 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize repmsentadvs 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
s4to-�
in conscqof granting of this It.
APPLICA U ERSTANDS AND I COMPLY WiTH ALY NON-INT
Issued by: Date ZO 0
SOUR ULATIONS.
Re -roofs
—
Type of Roof
20
SignaLurkkLLpntractor D tc
HAZARDOUS MATERIALS DISCLOSURE
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. Scction25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes �No
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 defined by the Bay Area Air Quality Management
all new materials for inspection.
❑Yes pGno
'ousmaterialsrequirementsunderChapter6.95orthecaliror-
IIt ehazard
nia Halth & cty Srxtions 25505, 25533 and 25534.1 understand W tf dhc building
does not ndy a rcnanl, War h is m ibility to notify the p of tic
�"�--
mqu ts wh ch tut be met prior to isms c o a Cartir or ev.
Signature of Applicant Date
Z+ d
All roof coverings to be Class's"" or better
Owner or d agent Dare