09050164CITE' OF CUPEKI11NU
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
2 INFINITE LOOP
'NER'S NAME:
APPLE rnmpuTFR —
PHONE:
ARCHITEC IENGINEER:
app LICENSED CONTRACTOR'S DECLARATION
v I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000)of Divi n 3 ofthe Business and Professions Co and my license is
n y in full force and effect _7
v� z License Cl s Lic. N
Date Contractor S,r
A CHITECTS DECLARATION
< 1 understand my plans shall be used as public records
�yU
tti y Licensed Professional
< OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following mason. (Section 7031.5, Business and Professions Code: Any city or county
4194 which requires a permit to construct, alter, improve, demolish, or repair any structure
y Z prior to is 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
xF (commencing with Section 7000) of Division 3 of the Business and Professions Code) 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 more than five hundred dollars (5500).
❑ 1, as owner of the property. or 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 Contracmrs 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.).
❑ 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 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 mason
,ner Date
WORKER'S COMPENSATION DELI-ARATION
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I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
sation, as provided for by Section 3700 of the tabor Cock, for the performance of the
work for which this permit is issued.
❑ 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 Compensa'on Insurance carrier and Policy number am:
Carrier. Its G Policy No.. C 2ADC9 CK T 3
RTIFICATE OF EXEMPTION 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, 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 worker's 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 (See. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that 1 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 convection, and hereby authorim 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 consequen the granting of this permit.
APPLIC DERSTANDS WIL OMPLY WIT" ALL NON -POINT
SOUR RE(f&ATIONS. /
Signal Iicanl/Contractor ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Mun' *pal Code. Chapter 9.12, and the Health and Safety
de, Section 25532(a)?
❑ Yes No
Will the applicant or futu building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes )I Nu
1 have read the hazard us�matenals requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505,25 and 25534.1 understand that if the building
does n tly have a tenant. tha ' is risibility, to notify the occupant of the
mqui mens p est
ich must be met 44- of a Cc ficate of 0f a
Owner or authorized agent 7 Date'*
SOUTH EAY
INC
(408)379-5500
Job Description
TEMP PERMIT, ADDING 2 CHAMBERS, ORIG #09050033
Sq. Ft. Floor Area
31602106.00
—2—
Issued
Issued b3
Re -roofs
Type of Roof
ME
Occupancy Type
Required Inspections
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 riaterials for inspection.
� I �T / - 2g I O
Signatury of Applicant Date
All roof coverings to be Class %*' or better
PERMIT NO.
N -CO
09050164
PERMIT ISSUE DATE
S A
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB MECH
Job Description
TEMP PERMIT, ADDING 2 CHAMBERS, ORIG #09050033
Sq. Ft. Floor Area
31602106.00
—2—
Issued
Issued b3
Re -roofs
Type of Roof
ME
Occupancy Type
Required Inspections
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 riaterials for inspection.
� I �T / - 2g I O
Signatury of Applicant Date
All roof coverings to be Class %*' or better