09030067 7777777777777
CITY OF CUPERTINO
BUILDING DIVISION PERMITS WTD ` '
PERMIT NO.
BUILDING ADDRESS:
20830 STEVENS CREEK BLVD SHAMES CONSTRUCTION 09030067
PERMIT ISSUE DATE
OWNER'S NAME:
-IYAR PRC)PEE TTES 5826 B TSA ST
S A CONTROL NO.
PmONE:
(925) 606-3000
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
i with Section 7000)of Division 3 of the Business and Professions Code,and my license is REV FIRE PUMP VOLTAGE FRM 12 5 H P TO 7 5 H P
y in full force and effect
License Class co#actor O R I G#0 8 0 9 016 6
finDate ARCHITECTS DECLARATION
< I understand my plans shall be used as public records
D,U
U.l- Licensed Professional
y 5 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
y—
In prior to its issuance,also requirts the applicant for such permit to file a signed sulement Ft.Floor Area Valuation
?< that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sfl
Y.E_ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 0
y 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than five hundred dollars(5500). 35908027 . 00
❑I,as owner of the property,of 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 Required Inspections
and Professions Code:The Contractor's License Law docs 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.).
❑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 docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a con=tor(s)licensed pursuant to the Contractor's
License Law.
Q 1 am e>;.Mpt under B&P C r thi assn
.,� Date
W R S COMPENSATION DF-CLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workces 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 Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or Icss)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any rson in any manner so as to become subject to the Workers'Compen ton
Laws of C tfa a
Applicant
NOTICE TO PLIC after making this Certificate of Exem on,you ould
become subject to the or s Compensation provisions of the Labor Code,you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constructinn lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
Lb:)Q Lender's Name
�z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
LL H correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection Purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Fh lA liabilities,judgments,costs and expenses which may in any way scenic against said City
V Z in consequence of the granting of this permit D e
►� APPLICA NDERSTANDS AND WILL COM)LY WI ALL NON-POINT Issued b-/:
SOURC GU S. !
Re-roofs -
Signature fAppli Co for Da
DOUS MATERIALS DISCLOSURE Type of.Zoof
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
1�de,Section 25532(a)9 /¢ All roof:;shall be inspected prior to any roofing material being installed.
❑Yes W N°
`.�f/c If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or futu tlding occupant use equipment or devices which
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new 1 naterials for inspection.
District?
❑Yes Na
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have a tenant that It is my respo 'hilhy Ion if the occupant of the
requi7orauthori
ch be motpriorroissuance CaC 'ficateo Oceapancy. Signatur-of Applicant Date
y All roof coverings to be Class'J�"or better
Owna t ate