09050031BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10420 E ESTA'
OWNER'S NAME:
O
Z, ,
ARC HIT'EGT/ENGINEEIL
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Jofrssions Code, and my license is
in full force and effect T2
License Class Lie, py 7 7 t✓ 'i
Date "� ` Conuwwr
A CHITECI'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from use Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Cotte: 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 licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars (5500).
❑ 1, as owner of the property, at 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 dors not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employers, 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 Contractees U.
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a canuacwr(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally 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.
❑ 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�Com�pensau Instu"mce carrier and Policy number ate:
Carrier. " PolicyNa.: / �3i
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I cenify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mannerso 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 tabor 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 performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lendces Name
Lendees Address
I certify that 1 have read this application and sate that the above information is
corteeL 1 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 property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON -POINT
SOURCE
� 7 oei
Signature l'ApplicanUContractor Dfile
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant 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)?
E3 Yes to
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 No
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
docs not currently have a ienam, that i�*_blfity to notify the occupant of the
requiremcn ich must he met priorCcnifcatgofOyErh�11IJ //
Owner or authorized agent Date
650) 325-9558
Job Description
REV, INSTL BEAM ASSEMBLY, ORIG #09040083
Ft. Floor Area
36925036.00
Required Inspections
Occupancy
Re -roofs
Type of Roof
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.
kw�a 44
�9
Signature of Applicant Date
All roof coverings to be Classor better
PERMIT NO.
ncincsoni
PERM" ISSUE DATE
SkM Att�
8 8 9
CONTROL N0.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
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Job Description
REV, INSTL BEAM ASSEMBLY, ORIG #09040083
Ft. Floor Area
36925036.00
Required Inspections
Occupancy
Re -roofs
Type of Roof
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.
kw�a 44
�9
Signature of Applicant Date
All roof coverings to be Classor better