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CITY OF CUPERTINO
PERMIT
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
10201 TORRE AVE 2ND FLR
TICO CCNSTRUCTI N CO
06
OWNER's NAME:
PERMIT ISSUE DATE
MP TOR -RF PT A7A TAT 191_O
S A CONTROL NO.
. AONE:
(408)4:9-0266
ARCHITECl7ENGINEER:
BUILDING PERMIT INFO
BLIX'i ELECT PLUMB MECH
a 0 0 a
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions gpde.and m`y license is
5 NEW L 100 R S 16 NEW LIGHTS , 6 0 0 S Q CEI LNG TILES
in fd t V
Lieenseullforce anS71CtaB
Dam Contractor
,
OFFITS, NEW CARPT&PNT
AR HrIECTS DECLARATION
I understand my plans shall be used as public records
i
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
i following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter. improve, demolish• or repair any swcture
Sq. Ft. Floor Area
prior to its issuance, also requires the applicant for such permit to file a signed statement
9
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
that
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$18000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
not more than five hundred dollars (s500).
3 6 9 41U 5 . FLR2
0 I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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 dors 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 We. 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
sate.).
0 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 U-
ccne 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.
0 1 am exempt under Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have and will maintain a Certificate of Consent to self -insure for Workees Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 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 Workees Compere, atiion urance carrier and Policy numberO 5�3��
02-O
Cartier. A t%%A1M� 4( VU - Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Ito 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 manner so as to become subject to the Workers' Compensation
Laws of California. Date
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
F~ forthwith comply with such provision or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued (Sec. 3097, Civ. C.)
~ Lendces Name
a Lcndees Address
DI 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 convection, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
nliabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
-� APPLICANT UND NDS AND WILL COMPLY WITH AL NON -POINT
Issued by: Date
SOURCE REGU ON .
` 11
Re -roof., --
Type of Roof
yP
SignarureofApplicaH ntrsctor °cele
H ARDOUS MATERIALS DISCLOSURE
Will the applic t 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 25532(a)?
All shall be inspected prior to any roofing material being installed.
Yes No
roof;
0
t
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or re building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new : naterials for inspection.
District?
❑ Ycso
1 haw read the hazard materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Section 25515, 25533 and 25534. I understand that if the building
does not currently h a ant, that it is my responsibility to notify the occupant of the
requirements whic must met prior to issuance of a Certificate of Occup2ficy.
Signature of Applicant Date
All roof coverings to be Class''" or better
\
Owner or authorized 9frrit Date