09050156 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
T+C?R I� RTI(3N:
BUILDING ADDRESS: PERMIT NO.
21979 SAN FERNANDO AVE YB CONSTRUCTIO
vNER'S NAME:
PERMIT ISSUE DATE
S A CONTROL NO,
PHONE:
L'T D 1tR
(408) :316-1261
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
opo LICENSED CONTRACTOR'S DECLARATION Job Description
v I= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in full force and effect. BLACKBI!RRY FARM — TEMP PERMIT FOR CONCESSION
j n Z License Class Lle• STAND
3 F Date Contractor
ARCHITECTS DECLARATION AREA 014LY ELECTRIC, MECH& PLUMBING; ORIG PERMIT
I understand my plans shall be used as public records
ra.4 #09020071 — NO INSPECTIONS AFTR 6/26/09
G I- Licensed Professional
OWNER-BUILDER DECLARATION
n 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
K Pi which requires a permit to construct.alter.improve.demolish,or repair any structure
Q Z y prior to its issuance,also requires the applicant for such permit to file a signed Late
_ that he is licensed pursuant to the Provisions of the Contractor's License Law(Chapter 990
Sq.Ft.Floor Area Valuation
F$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100
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 APN Number Occupancy Type
not more than ere hundred dollars(M). 357100,)5 . 00
❑I,at owner of the property,or my employers with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License: rs Law donot apply to an owner of q p
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.).
ZIT 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-
ccnse 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.
❑lam
exempt under Sec. B&P C for this reason
vncr% Ca-, /. �—tom, Date C 2—
COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 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 carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fix 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.DateS
Applicant 1
NOTICE TO APPLICANT:If,after rAlldng this Certificate of Eicmption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
HI 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.)
aQ Lender's Name
=Z Lender's Address
U C) I certify that I have read this application and state that the above information is
(7r correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
►F-d liabilities,judgments,costs and expenses which may in any way accrue against said City /
V Z in consequence of the granting of this permit Date Z` S
h"d APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
C 2 ej'�4 5 Re-roof:i
Signature of A cant/ConLractor Dae T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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
ode,Section 25532(a)? All roof s shall be inspected prior to any roofing material being installed.
C3 Yes o
Will the applicant or foto building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
1 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 currently have a tenant.that it is my responsibility to notify the occupant of the
rcyuirem whic�t be me_"or to!ppance of a Ceruficate of Occupancy. 1 S ignatul a of Applicant
Date
All roof coverings to be Class'JW'or better
Owner or authorize agent Date