09040041BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19333 VALLCO PARKWAY FERMA
OWNER'S NAME:
ARCH117ECrfENGINEER.
adz
LICENSED CONTRACTOR'S DECLARATION
i 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
�< H in full font and ect f 3
t Z Lice lac Cl a L, i to
F Detc G Contractor
ARCHITECT'S DECLARATION
i I undersuod my plans shall be used as public records
Ira
O Licensed Professional
y OWNER -BUILDER DECLARATION
T hereby affirm that 1 am exempt from the Contractors License Law for the
p O following mason. (Section 7031.5, Business and Professions Code: Any city or county
i$ � which requires a permit to construct, alter. improm demolish, or mpair any structum
z prior to is issuarue, also mquires die applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors Licermsc Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
.. that he is exempt Lhemfrom and the basis for the alleged exemption. Any violadon of
Section 7031-5 by any appLkurrr for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SW.
❑ 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 forsale (Sec.7044. Business
and Professions Cads The 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 employed, provided that such improvements are not intended or oRered for gala If,
however, the building or improvement Is sold within one year of completion, the owner.
builder will have the burden of proving that be did not build or improve for purpose of
tale.).
❑ 1. as owner of the property, am exclusively contracting with limnsed contractors to
ronw= the project (Sec. 7044. Business and Professions Code:) The Contractors U.
tense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a cum aclor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this mason
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-insum for Workers Compen-
sation, 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 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 Workers Compensation hutunnce carrier and Policy number arc:
Carrier. ^J�"ICbT�P Policy No.:5:flm oo b (4
CIIrmcATE OF ExEMPI]ON FROM WORKERS
COMPENSATION INSURANCE
(Min section teed not be completed if the permit Is for one hundred dollars ($100)
or less)
1 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, alter making this Certificate of Exemption, you should
become subject to the Workerem s Compaatim provisions of the Labor Code, you must
Oforthwith comply with such provisions or this pamil shalt be deemed revoked.
f
N nr CONSTRUCTION LENDING ENDING AGENCY
4 1 hereby affirm that them is it construction lending agency for the performance of
1! , the work for which this permit is issued (Sec. 3097, Civ. C)
4 Q Lenders Name
z Lenders Address 1 eerily that 1 have read this application and state that the above information is
correct 1 agree to comply with all city and county ardinarims and state laws relating to
building construction, and hereby authorize mpmsenutivcs of this city to enter upon the
W above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
yr/3 liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permiL
APPLI ANT 1.�IDMS-rANS1-L COMPLY WITH ALL NO -POINT
SOURC REt7(1
D �
Sign7.mcd
ApplicanUCon or Date
US MATERIALS DISCLOSURE
Use applicant future building occupant store or handle hazardous material
as y lire poMunicipal Code, Chapter 9.12, and the Health and Safety
C , Section 2553 /
[]Yes
o
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?
❑ Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of Lhc Califor-
nia Health & Safety Code, Sections 255IL5.25533 and 25534. I undcrsand that if the building
does not c n0y hale s tenant, tar is my recponsthility to notify the occupant of the
require whit m t prio issuance of a Certificate Otte
a 0
Own or authorind a nt I i Date
(650)961-2742
PERMIT NO.
09040041
PERMIT Lc3UE DATH
A
CONTROL NO.
BUILDING PFRMrr INFO
BLDG
ELECT' PLUMB - MECH
Job Description
ABATEMENT & INTERIOR DEMO
Sq. Ft. Floor Area
31620075.APL
Required Inspections
Issued by: 1,411LMow!
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date / " �o- -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 in' or better