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09030059yoo Use R yF� �aU : a i - U .ya n pC _ Rz> Y CITY OF CUPERTINO DIVISION PERMITS T . BUILDING BUILDING ADDRESS: PERMIT NO. 19620 STEVENS CREEK B= TE TBD — TO BE DETERMINED n,qn_7k_Mr)9 OW NIR6 GAME: PERMIT ISSUE DATE PHONE: A Ol CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT IN BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION fob 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, and my license is in full force and effect.�3 7G Ll. it T.I.—BANK INTERIOR, INCLUDES CONST OF NEW OFFICE License Class r Date — �� ContractOL:5- r;zp©T— RM, CONFERENCE RM, RESTROOMS AND BANK TELLER A HITECTS DECLARATION II I understand my plans shall be used as public records L INE . 6 , 5 9 6 ' Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 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 We a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or 6 5 0 0 0 0 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($500). 36906010 STE 16 0 ❑ I, as owner of the property, or my employees with wages as their sole compensation, Required Inspections q P 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 dam 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.). ❑ 1, 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. ❑ I am exempt under Sea B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty 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. ❑ I 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. m: P My Worker's Compensation Insurance carrier�d Policy number am- Carrier.0 (" Piz LJ((jdholicyNo.:o G IWZ Carrier. CERTIFICATE OF EXEMPTION FROM WO ERS' COMPENSATION INSURANCE (This section need not be completed if the permit is far 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 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 Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. ) + CONSTRUCTION LENDING AGENCY 4 1 hereby affirm that there is a construction lending agency for the performance of 4 the work for which this permit is issued (Sec. 3097, Civ, C.) Lender's Name • Lender's Address j I certify that I have read this application and state that the above information is + cored I agree to comply with all city and county ordinances and state laws relating to + building consuuction, and hereby authorize representatives of this city to enter upon the inspection ? above-mentioned property for purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against, J liabilides,judgmenis, costs and expenses which may in anyway accrue against said City in consequence of the granting of this permit I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date �( V SOURCE REGUL TIONS. — Re -roofs Type of Roof Signature of Applicant/ tractor Date H ARDOUS MATERIALS DaLOSURE Will the applicant or future building occupantstore or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely Code, Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑ Yes ,,rNo 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 JIJn° I have read the hazardous materials requirements under Chapter 6,95 of the Califor- nia Health & Safely Cade, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant, that It is my responsibility to notary the occupant of the requirementswhicjrmu t be met pri to issuance of certificate or occupancy. Signature of Applicant Date G 1 All roof coverings to be Class "'}`` or better Owner or authorized age l Data