09040077 CITY OF CUPERTINO �^u
BUILDING DIVISION PERMIT 4� k�ATC? I� M �
BUILDING ADDRESS: PERMIT NO.
10101 BUBB RD NOVO CONSTRUCTION 0904QO77
PERMIT ISSUE DATE
ER'S NAME:
S A CONTROL NO.
PHONE:
(650) 7)1-1500
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
a0Zo LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is C,01 ,L TI OF EXT BLDG, 1 NEW WALL & 1 NEW OPENING
' y in full force and effecK - 'Z__
z License Cl L�.�► l -' (1430S)) ; NO STRUCTURL
Date Comractor.
ARCHITECTS DECLAMOK
a< I understand my plans shall be used as public records
X06
4 O y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby atrhrm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m 9 which requires a permit to construct,alter,improve,demolish,or repair any structure
u Z y prior to is issuance,also requires the applicant for such permit to file a signed statement Valuation
x G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
yt-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $48000
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). 35720003 . 00
0 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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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.).
0 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 contractor(s)licensed pursuant to the Contractor's
License Law.
0 1 am exempt under Sec B&P C for this reason
lerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I 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.
0 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 Worker's Compensation Insurance carrier and Policy number am: q p
Carrier eMdLW_ kW QCh111- PolicyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
1 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 Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z RCONSTRUCTION LENDING AGENCY
[~i her I hereby affirm that there is a construction lending agency for the performance of _
R!> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendces Name -
? Lender's Address
V 0 1 certify that I have read this application and state that the above information is
VL h-r cored I agree to comply with all city and county ordinances and state laws relating to
O Vbuilding construction,and hereby authorim representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
indemnify and keep harmless the City of Cupertino against
LL )agree save
CA liabiliyies'udgmcn ,cc and expenses which may in anyway accrue against said City ,l
V z co rtes oC a ting or finis pc Date
Z inS �(_a
I n U DE ANDS AND L COMPLY WITH A LNON-POINT Issued by:s0 R G A NS. y[510-1'f Re-roof s
Sign re of Applican ontractor Date
H DOUS A ALS DISCLOSURE Type of Roof
Will the applicant or future ng occupant store or handle hazardous material
as do ed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
,de,Section 25532(x)? All roo''s shall be inspected prior to any roofing material being installed.
Ya
If a;,'is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices whichemit hazardous air contaminants asdcfy the Bay Area Air Quality Management all $ for inspection.
District?
0 Yes No
1 have ad the hazardous materials requirements under Chapter 6.95 of the Califor.
nix Ith& cty Cade,Sections 25505,25533 and 25534.I understand that if the building
d t c dy ve a tenant?Y;responsibility to notify the occupant of the
qui me hi must etatuec of a Certificate ofU pan Signa t i e of Apicant Date
S D All roof coverings to be Class" "or better
w
Ocr or authorized agent Datc