09020041 CTTY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS: PERMIT NO.
21111 STEVENS CREEK BLVD CUPERTINO ELECTRIC INC 09020041
OWNER'S NAME PERMIT LSSUE DATE
PHONE
S CONTROL NO.
(408) 991-1000
ARCHITECTIENGLNEEE BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
•u p C LICENSED CON•IRACI'OR'S DECLARATION
I hereby affirm that I am li¢naed.under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Coda.and my Berens=Is
y in full force and effect INSTL NEW TENNIS COURT L I GHTNG FIXTURES & SOME
D el i Licuue Class L ic.0
9 M w Dater contra= NEW
a ARCHrrECT`S DECLARATION
I understand my plan s shall be used as public records POLES
D,U
Q y Licensed Professional
si y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from site Conumads License Law for the
C following reason.(Section 70315,Business and Professions Cade:Any city or County
e fut which requires a permit to eomaruct,alter,improve,demolish,or repair any urucmm
z y prior to its issuance,also requires the applicant for such permit to file a signed Fame r
z o that he is licensed pursuant to the provisions of the Conawtoh Llrrnac taw(Chapter 9 Sq.Ft.Floor Area Valuation
Y F- (commencing with Section 70D0)of Division 3 of the Business and Professions Code)or 0
y that he is exempt therefrom and the baste for the alleged exemption.Any violation of
Seaton 7031-5 by any applicant for a permit subjects the appilnnt to a Civil penalty of APN Number Occupancy e
m not mom an tiw hundred dollars($500). 32629022 .TNS CRT P y TYP
❑L 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
and Professions Code The Contractor's License Lew does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such wart hlmaelf or through his
awn employees,provided that such improvements are not intenndcd or offered for sales If,
however,the building or improvement Is sold within one year of completim the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale,).
m L as owner of the property,am exclusively contacting with licensed=mKiors to
conauo 1 the project(Sec- , =ness and Professions Cade:)The Caatractoh Li-
cc�hse Law doer not apply to an who builds or improves thereon,and.
who tuact3 r such pro' th a &c=d pursuant m the contactors
L.Iranse Lave.
❑I am exempt ern ,B&P C for this reason
Owner Dare 6"
WO '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-Insum for Worlds Compen-
sation,as provided(or 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 Coro,for the performance of the work for which this permit is r--A
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
Lt-Ki FICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This sectioWrp-fork
the permit is far one hundred dollars(S100)
or leer)
t certify that th the for which min permit is issued,l shall not
employ any personome subject Lo the Worke11'Compensator
Laws of California.
Applicant
NanCE TO PLl :If.after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you smut '
0 O forthwith comply with such provisions or this penait shall be domed revoked.
z� CONSTRUCTION LENDING AGENCY
►En•+ I hereby affirm that these is a construction lending agency for the performance of
p:> the work for which this permit is issued(See.3097.Ckv.C)
(der Q Lendcds Name
z L.endds Address
V I certify that I have tad this application and state that the above infomtadon is
Uf correct.I agree to comply with all city and county ordinances and state laws relating to
o building construction,and hereby authorim representatives of this City to enter upon the
W above-mentioned o
ID. (We)agree-td save,indemni and keep
y of cupcnirro against
,.., liabilities,Judpncns,taus and es which y iarue againu said GqU 7 in consegde:nce of the gnttdn is permr� APPL1cAM UNDERTS Y WITH ALL NON-POINT Issued by: Date /
SOURCE REG
p-�-- Re-roofs
Signature of Applica Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9-1Z and the Helth and Safety
Code.Section 25532(a)7 All roofs shall be inspected nor to an roofing material being installed.
❑Yes �No P P � Y g g-
Wfll the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as dellned by the Bay Area Air Quality Management all new materials for inspection.
District?
El Yes o
I
aves mad the mclu' Chapter 6.95 of the Callfo-
nia Health h Safey Cade, 25505.25 .1 understand the If the building
does not currently '�it' nsibility to notify the occupant of the
i S
mquiremcnm which Ise met rssuancc of a certificate of Signature of Applicant Date
wnaorauthorvedagent Ddic' All roof coverings to be Class'n'or better
1 _