09040163CITY OF CUPE
BUILDING DIVISION PERNUT
BUILDING ADDRESS:
PERMIT NO.
4 INFINITE LOOP
DPR CONSTRUCTION INC
63
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
A O. CONTROL NO.
(650) 47.4-1450
ARCHriECr/ENGINEER:
BUILDING PFRMrrIN[-0
13LDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
i hereby affirm that I ant licensed under provisions of Cbapler 9 (commencing
-
winiullS mnandeffcoftDivision3of hcBusiness andProf omCnde,andmyliexnse s
DEMO INTER NON —BEARING PRTNS & FINSHS
License Gala '� Lm. r `-' ' -� �- Y e.
!! .
Date Contractor Ple
CHITECPS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct, alter, Improve, demollsb, or repair any structure
'
prior to its issuance, also nmquires the applicant for such permit to rile a signed sulcmeru
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 Code) or
8 9 5 0 0
that he Is exempt therefrom and the basis for the alleged curnpdon. Any violation of
APN Number
Occupancy
p y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
31602108 .04
❑ 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.70", Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improve& thereon, and who does such work himself or through his
own employ=, provided that such improvements are not intended or offered for sale. If,
however, the b uilding 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
We.).
❑ L as owner of the property. am exclusively Contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractors LI-
eense Law does not apply to as owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of Inc following declarations:
❑ I hive and will maintain a Certificate of Consent to self -insure for Workers Compan-
sadon, 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 performance of the work for which this permit is Issued.
'
My Workers Compensation Insurance carrier and Policy number are:
CaR1er-.NIYiL ✓n/: c;r� F'�'& Policy No.:t 70 - .���
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section teed not be completed if the permit Is for one hundred dollars (5100)
or less.)
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.
CONSTRUCTION LENDiNa AGENCY
i harehy if1Lm that there is a construction lending agency for the Performance of
the work for which this permit is issued (Sex. 3097, Civ. C.)
Lenders Name
,
Lenders Address
I certify That I have read 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 construction, and hereby authorize rnpresentallves of this city to enter upon the
above-mendoned property for inspection purposes.
(We) agree to save, indemnify and keep harmless Ibe City of Cupertino against
Habilities,f udgmenis, costs and expenses which may in any way acme against said City
in consequence of the granting of this permiL
APPLICANT UNDERSTANDS AND WiLL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REG ONS.
Re -roofs
Type of Roof
l4yr
�phant/cu OUS LS DISCLOSURE Da
Will the applicant or future but g occupant sore or handle hazardous material
as defined by the Cupertino Municip Codc. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
Cl Yes
All roofs shall be inspected prior to any roofing material being installed.
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
cmli hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District[
[I Yes �?16
1 have mad the hazardous materials requimmenLs under Chapter 6.95 of the Califon
nia Health & Safety Code, Sections 25505.23533 and 25534.1 understand that if ciao building
does not currently have a tenant that it Is my res 'bility to notify the t of the
requimman ni nst be met prior to issttancc . certrrtcae nrOccupun .
Signature of Applicant Date
mid O
All roof coverings to be Classor better
iu
mar or ied agent Da