09040023BUILDING DIVISION PERMIT
BUILDING ADDRESS:
_ 10123 WOLFE RD ROSS CO:ISTRUC
0%VNER'S NAME:
L,riUNE:
ARCHITEC (ENGINEER:
u p C LICENSED CONTRACTOR'S DECLARATION
V
I 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
= 0- in full force and effect
Z License Clasa Contractor
3
it a ► Date
ARCHITECTS DECLARATION
J � < I understand my plans shall be used as public records
DLU ra6u
Oy Licensed Professional
N 3 OWNER- BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
in O following reason. (Section 7031.5, Business and Professions Code: Any city at county
e m 0! 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
Z < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Yt=- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he is exempt thegefrom 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 penally of
not more than five hundred dollars (5500).
❑ 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
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves themon, 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 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.
❑ 1 am exempt under Sec . B & P C for this reason
^. ner Date
WORKER'S COMPENSATION DECLARATION
I hereby afl'trrm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure 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.
❑ 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 Workers Compensation btsurance carrier and Policy number are:
Carrier. ��is &140 Polity No.: -Tl 30030714
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('(Lis section need not be completed if the permit is for one hundred dollars ($100)
or Icss)
I certify that in the performance of the work for which this permit is issued, 1 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 Workers Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0� CONSTRUCTION LENDING AGENCY
F~t V3 1 hereby affirm that there is a construction lending agency for the performance of
iYr the work for which this permit is issued (Sec. 3097, Civ. C.)
W A fenders Name
0 z Lenders Address
1 certify that 1 have read this application and state that the above information is
U cored I agree to comply with all city and county ordinances and state laws relating to
0 V building construction. and he by authorize representatives of this city to enter upon the
above -mcnti property tnspcctian purposes
u a iWc) g e to sa dcmnify and keep harmless the City of Cupertino against
Hliabilities, j g cnt��t .c d ex hich may in any way scene against said City
U z in conseq offie this permit
t--i ppp ANDS AND WILL COMPLY WITH ALL NON -POINT
Nsewiq tt Date
ZARDOUS MATERIALS DISCLOSURE
icant or future building occupant store or handle hazardous material
upertino Municipal Code. Chapter 9.12, and the Health and Safety
2(a)? 4KNo
Will t he 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
1 have rc a materials requirements under Chapter 6.95 of the Califor-
nia Health & S y ode. 25505, 25533 and 25534.1 understand that if the building
does t carte ve tify the occupant of due
m et prior to issuance of a CenificatW Occypancy._
(408)225 -1187
PERMIT NO.
PERMIT ISSUE DATE
Sx CONTROL No.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
0 0
Job Description
DEMO PARKING LOT (255,384 SQFT)
INc
. Ft. Floor Area
31620089.LOT
Issued b-
Re -roofs
Type of Zoof
2
Occupancy Type
Required Inspections
All roof:: 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 I naterials for inspection.
Signatur,_ of Applicant Date
All roof coverings to be Class 'W' or better