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09040028BUILDING DIVISION PERMIT Carrier.Policy No,: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('Ibis section need not be completed if the permit is for ono 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 manner sp as, to become subject to the Workers' Compensadon Laws of California Applicant ! NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance of jY, rT the work for which this permit is issued (See. 3197, Civ. C.) (� A Lender's Name ,D Z Lender's Address U 0 I certify that I have read this application and state that the above information is Lt+ correct I agree to comply with all city and county ordinances and slate laws relating to 0 U building construction, and hereby authorize representatives of this city to enterupon the above-mentioned property for inspection purposes. - (We) agree to save, indemnify and keep harmless the City of Cupertino against mHy (n liabilities, judgments, costs and expenses which may in any way accrue against said City U 7 in consequence or the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURC REG ATIONS. % Sil,%ni'c oCA plicanUConlracmr Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore or handle hazardous material as dcftnod by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes PO No 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 District?tt�� []Yes q�No I have read 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 cu Oy, have a tenant, that it is my responsibility to notify the occupant of the rcyuircmcn bleb t be mel prior to issuance of a Certificate of cup cy. L///W n Owner o authorized agent Dale Issued by: Re -roofs Type of Roof Date �- —11":7, 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 all new materials for inspection. Signature of Applicant Date All roof coverings to be Class 'A" or better BUILDING ADDRESS: PERMITNU. , 19620 STEVENS CREEK BLVD STE GREAT -WALL BLDG CONTRACTOR nqn4n028 OW NgR7 GAME: INCPERMIT ISSUE DATE PHONE: A CONTROL NO. (510) 589-7528 ARCHITEC IENGTKEER: BUILDING PERMIT INFO BLDG ELECT PLUMB - MECH o zo LICENSED CONTRACTOR'S DECLARATION Job Description v )= Ihereby affirm that I am licensed under provisions of Chapter 9 (commencing Z � H an 00) ecDivislon 3 of the Business and Professions Code, and my license is in Cull force and effect. in full force REVISION ,LIGHTING , ADDWALLS & MECHANICAL j Z F,m License Class Lic. # Data Contractor .5 SHAFT. e ARCHITECTS DECLARATION I understand my plans shall be used as public records NEW PARTITIONS, CEILING DOORS ETC, ORIG #08090177 CEILING,DOORS V Licensed Professional w N y OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the .00 following mason. (Section 7031.5, Business and Professions Code: Any city or county m 9 which requires a permit to construct, alter, improve, demolish, or repair any structure its issuance, requires the applicant for such permit to rile a signed statement z r `e prior to also that he is licensed pursuant to the pmvisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation F $ (commencing with Section 7000) of Division 3 mf the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of 0 APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars ($500). 36906010 . S 17 0 ❑ 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 or offered for sale (Sec. 7044, Business and Professions 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 owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). M 1, as owner of the properly, am exclusively contracting with licensed contractors to donsimct 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. ❑ I am exem/ pt and See. , B & PS reason Owner C/ for ibis /� / Dale r m o C 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 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 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 are: Carrier.Policy No,: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ('Ibis section need not be completed if the permit is for ono 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 manner sp as, to become subject to the Workers' Compensadon Laws of California Applicant ! NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must ,J Z forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there Is a construction lending agency for the performance of jY, rT the work for which this permit is issued (See. 3197, Civ. C.) (� A Lender's Name ,D Z Lender's Address U 0 I certify that I have read this application and state that the above information is Lt+ correct I agree to comply with all city and county ordinances and slate laws relating to 0 U building construction, and hereby authorize representatives of this city to enterupon the above-mentioned property for inspection purposes. - (We) agree to save, indemnify and keep harmless the City of Cupertino against mHy (n liabilities, judgments, costs and expenses which may in any way accrue against said City U 7 in consequence or the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURC REG ATIONS. % Sil,%ni'c oCA plicanUConlracmr Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore or handle hazardous material as dcftnod by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes PO No 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 District?tt�� []Yes q�No I have read 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 cu Oy, have a tenant, that it is my responsibility to notify the occupant of the rcyuircmcn bleb t be mel prior to issuance of a Certificate of cup cy. L///W n Owner o authorized agent Dale Issued by: Re -roofs Type of Roof Date �- —11":7, 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 all new materials for inspection. Signature of Applicant Date All roof coverings to be Class 'A" or better