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CITY OF CUPERTINO—:�:——�-
DIVISION PERMIT��'�''�7k�:`
BUILDING
BUILDING ADDRESS:
PERMIT NO.
10919 N WOLFE RD
TBD — TO BE DETERMINED
OWNER'S NAME:
PERMIT ISSUE DATE
:
A CONTROL NO.
ARCHIl1:CT/ENGTNEER:
BUILDING PERMiTINFO
BLDG ELECT PLUMB MECH
0 0 0 0
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, snd my license is
inracensc�aand effect
V
IINSTL ILLMNTD INDVL CHNL LTR SIGN@ FRWT OF STORE
LIC.s
Date Contractor
ARCHITECTSDECLARA
I understa d my plans shall be used as public records
Lwtnscd Professional
OWNFR-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License law for the
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 structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is liccnsod pursuant to the provisions of the Contractors License law (Chapter 9
Sq. Ft- Floor Area
-
Valuation
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the aucged exemption. Any violation of
15 0 0
APN Number
Occupancy
P y • J Pe
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
316 0 5 0 51 . YGRT
❑ I, as owner of the property, or my employcea 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 owrcr of
property who builds or improves thereon, and who does such wort himself or through his
owns employees, provided that such improvements are not intended or offered for sale. It,
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 mwner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
ceau Lzw does not apply to an owner of property who builds or Improves thereon, and
who convicts for such projects with a conuactw(s) licensed pursuant to the Conractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 hire 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 wh ch this permit is issued.
ve and will maintain Worlters Compensation Insurance, as required by Section
3 00 of the Labor Code for the performance of the work for which this permit is issued
My Workers ompensati Insurance airier end Policy number ere:
' F ?�u�y�y(3
Cartier.Policy No-:
CEFMFI OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed If the permit Is for one hundred dollars ($100)
or Iczc)
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
forthwith comply with such provisions or this permit shall. be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the perform-ca of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and stale 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 authoria representatives of this city to enter upon Lite
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
IiabilWes,judgmeaa, costs and expenses which may in any way accrue against said City
of this D WILL
A1)
-roofs
—
Type of Roof
/�� D
Slgnaturc of Appli t/Contractor Datc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as de0ned by the Cupertino Municipal Code, Chapter 9.1 Z and the Health and Safety
Code, Section 25532(a)7 /
Yea
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
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
all new materials for inspection.
District?
Yes
❑
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currerhdy have s tenant. that It is my responsibility to notify the occupant of the
rcquiremc a Certificate VOc anry.
Signature of Applicant Date
All roof coverings to be Class'.'' or better
Owner r authorized agent atc