09050124CITY OF CUPEKYINU
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
18922 FORGE DR
NER'S NAME:
ARCHITEC (ENGINEER:
chi
00 LICENSED CONTRACTOR'S DECLARATION
U C 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z m with Section 7000) of Division 3 of the Business Professions Code, and my lice is
? y in full force and effect. r e^
z Licenac Lic. k
Dao Contractor
ARCH;i S DECLARATION
1 derstand my plans shall be used as public records
�yU
L tu0 y Licensed Professional
y OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason. (Section 7031.5, Business and Professions Code: Any city or county
14-29 which requires a permit to construct. filler. improve, demolish, or repair any structure
y " Ih prior to its issuance, also requires the applicant for such permit to file a signed statement
'E G 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 Codc) or
y .. that he is exempt therefrom 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 penalty of
not mem than five hundred dollars (5500).
0 1, as owner of the property, or my employees with wages as their sok compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Conuacoes 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.).
0 I, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
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 Contracoes
License Law.
I I am exempt under Sere. B & P C for this mason
0 O
Z R
N
h --e
a Q
Z
UO
w E,
OU
a
V2
UZ
hH
mer Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the labor Code, for the performance of the
work for which this permit is issued.
0 1 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 Worker's Compensation Insurance carver and Policy nu her am: �
Carri >r{ 12�110tp Policy No..
CERTIFICATE F EXEMFnON FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I 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. after making this Certificate of Exemption, you should
become subject to the Workces Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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.)
Lenelces Namc
Lenders Address
1 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 authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemn' y and keep harmless the City of Cupertino against
liabilities,judgmcnta, cos and ex nscs which may in any way accrue against said City
in
co
of the g g o is permit
APPLIC NDE .N AND WILL COMPLY WITH AL NON- OINT
SOU S•
Sign of pplicant/Contracor Date
HAZARDOUS MATERIALS DISCLOSURE
ill the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
ode, Section 25532(a)?
e 0 Yes ItJ' No
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?
0 Yes lu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety C Sec'ons 25505, 25533 and 25534.1 understand that if the building
docs not cu my ha brit it is my responsibility o notfoaupan} of the
requirem hch mel prior to issuance of a Certificate o panty 7
ML
Job Description
ADDITIONAL PARKING LOT LIGHTING — SAN JOSE
ELECTRIC RENEWD BUS LIC 5/19/9
Sq. Ft. Floor Area
31609030.00
Issued by
Re -roofs
Type of F.00f
Occupancy Type
Required Inspections
l 4
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
All roof coverings to be Class'n" or better
Date
PERMIT NO.
PERMIT ISSUE DATE
S Ai VU 2 8 6 9
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB MECH
o a
0 0
Job Description
ADDITIONAL PARKING LOT LIGHTING — SAN JOSE
ELECTRIC RENEWD BUS LIC 5/19/9
Sq. Ft. Floor Area
31609030.00
Issued by
Re -roofs
Type of F.00f
Occupancy Type
Required Inspections
l 4
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
All roof coverings to be Class'n" or better
Date