09040123WZ
00
LU
CITY OF CUPERTINO
DIVISION PERMIT
BUILDING
BUILDING ADDRESS:
PERMIT NO.
21710 STEVENS CREEK BLVD #135
TBD — TO BE DE
OWNER'S NAME:
S A CONTROL NO.
ARCHiIECTIENGINEER
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70(10) of Di on 3 of the Business and Professio Code, and my license is
in fall force and eff,C
OML T I (8 0 0 S Q)
u«mere Lk.r
Da0.
leConlraclor
��Lv)
Ci-S DECLA ]O
1 used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors Liccnse Law for the
following reason. (Section 70313, Business and Professions Cady. Any city or county
which requires a permit to Construct, alter. improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he Is e¢atpt t erdfrom and the basis for the alleged eanoplioa Any violation of
2 2 0 0 0
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)6
35717038.135
❑ L as owner of the property, or my employees with wages as their sole amtpertsadon,
Required Inspections
will do the work and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: fle contractors 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 arc 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.).
❑ L as owner of the property, am exclusively contracting with licensed Contractors to
construct the project (Sec 7044. Business and Professions Code:) ''he CootracWs LI-
coase Law does not apply w an owner of property who builds or improves thereon, and,
for such projects with a conuractor(s) licensed pursuantw the Contractors
ZIcontracts
am exe nder--Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensadon Laurance, as required by Section
3700 or the Labor Code, for the performance of the work for which this permit is Issued.
My Workers Compensation Insurance e�Nagrz and Policy number are:
Cartier. 1:L Policy No.:
CERTlFlCATE 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 tb performance f the worn for which this permit is issued, 1 shall not
employ any
revoked.
CONSTRUCTION LENDING AGENCY
1 hereby ,firm dire there Is a construction lending agency for the performance of
the work for. which lids permit Is issued (Scc. 3097, Civ. C-)
Lenders Name
,
Lenders Address
1 certify that 1 have read this application and state that the above Information Is
cornett 1 agree to comply with all city and County ordinances and sate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mendoried property for Irspcction purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabilides,judgmenLs, coati and expenses wtlich may In any way accrue against said City
in consegtrertce granting of this
APPLICANT STANDS A L CO L WITH ALL ON-P INT
Issued by: Date
SOURCE
DISCLOSURE se
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 2ss3z(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
WIII he applicant or future building occupant use equipment or devices which
emit hazardous air contaminants ss defined by the Bay Area Air Quality Management
all new materials for inspection.
District7
❑ Yes No
1 have road the hazardous mareri requircm under Chapter &95 of the Califor-
nia Heal cry Code. Sections 533 5 I unelcrsraad th the 'ldins
eleq not
a1C