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CITY OF CUPERTINO
DIVISION PERNIITT�"
BUILDING
BUILDING ADDRESS:
PERMIT N0.
10123 N WOLFE RD STE 1095
TBD — TO BE DETERMINED
09030063
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
A CONTROL NO.
ARCHITECTlENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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 Code, and my license is
in roll force
ROOF SCREEN ON AMC ROOF 2 5 8 SQ
and effect.
License Class Lic. #
'
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70315, Business and Professions Code: 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 rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
9 O O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
31620081 . STE 10 9 5
❑ 1, 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 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 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 Pr fessions Code:) The Contractors Li.
cense Law does not apply to an ow r f pr who lids or improves thereon, d,
who contracts for such projects wi a o () lie d pursuant to the ontr tor's
License Law.
❑ I am exempt under Sea , B & P Cr�(I re
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm 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 peril 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 far one hundred dollars ($100)
or less.)
I certify that in the Performa: the work r hich}�' permit is issued, I shall not
employ any person in any marl r to b m st a to the Workers' Compensation
Laws of California, Date
Applicant
NOTICE TO APPLICIf, after making this Certificate of Exemption, you should
become subject to the orklers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peril shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a conslnrction lending agency for the performance or
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Landers Address
I 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 construction, and hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
sty
liabilities, judgments. costs and expenses which may in any way accrue ago'i7o
in consequence of the granting of this permi
APPLICANT UNDERSTA ND L OMP WITH AL
Issued by: Date
SOURCEREGULATION
Re -roofs ��-
Type of Roof
Signature or ApplicanUContraclor D te
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future builds occupant store or handle hazardous material
as defined by the Cupertino Munic' Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminan�dcfmcby the Bay Area AirQuality Management
all new materials for inspection.
District?
❑Yes
I have mad the hazard quirements under Chapter 6,95 of the Califo
niaHeal th&Safety Code, Sc tians255115,25533an 534.Iunderstandlhatifth buil' g
does not currently have a to 4 that it is m nsihility to notify the n the
'�
requirements whichm port an ora crtifrcateorOcc r
Signature of Applicant Date
c
All roof coverings to be Class "" or better
Date
Owner or authorixcd agent