090201130
CITY OF CUPERTINO PERMIT
MIT
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BUILDING DIVISION Y�ii
BUILDING ADDRESS:
PERMIT NO.
19620 STEVENS CREEK BLVD
SAN JOSE CONSTRUCTI
OWNER'S NAME:
PERMUISSUEDATE
PHONE:
sA NVA CONTROL NO.
(408)986-8711
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
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 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
REV, PATIO LIGHT POLE, STRCTRL CALLS&DET4IL; ORIG
License Class Lic. #
Date Contractor
#07060128
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
-
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
ollouveg.maeen.{Scction..7f13.1S, R� emcee and3mfcsstons Codc Any ci(yor count
whrch requires a-perrnit.to constiucl-aTtcr;lrtipmvc dem l pr tepmr-anystrdcturc`
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
License Law 9
that he is licensed pursuant to the provisions of the Contractor's (Chapter
s
(commencing with Section 7000) of Division 3 or the Business and ProressionCode) or
0
I that he is exempt therefrom and the basis for the alleged exemption. Any violation o
APN Number
Occupancy Type
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
36906010.00
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q P
will do the work, and the structure is not intended oroffered for sale (Sec.7044,Business
and Processions 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 owncr-
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 cpntracLs for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑' 1 am exempt under Sea , B & P C for this rc on
Owner (l: / �r Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I 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 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 Workers Compensation Insurance carrier and Policy number are:
Carrier, —•'i / Policy No.:
9 CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is for one hundred dollars ($100)
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 manna $$q as t become subject to the Workers' Compensation
Laws oC Califon R. Dale `�
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
forthwith comply with such provisions or this permit, shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
0 I hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lcndees 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 representatives of this city to enter upon the
above-mentioned property for inspection purposes.
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
in City
o) liabilities, judgments, costs and expenses which may any way accrue against said
> in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
RCE j3 .1 ONS, /'
SOURf!/
Re -roofs —
Type of Roof
—
Signature- of AppilcantlConlractor Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanlslore or handle hazardous material
as 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.
❑Yes MNo
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.
District?
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the Cali for-
nia Heal th & S afety Code, Sections 25505, 25533 and 25534,1understand that1fthe building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requi�/� wnie must be mel prior to issuance oCa Cenificam o y� � Yv C,
Signature of Applicant Date
f
All roof coverings to be Class 1;�.” or better
Owner or authorized agent D„�