09040146BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19620 S'
OW NIPS DAME:
ARCHITECT[ENGINEER:
v o o LICENSED CONTRACTOR'S DECLARATION
W t= I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
L) with Section 7000) of Division 3 of the Business and Professions Code, and my license is
y in full force and effect' 6
Z License.Class Lie, ti
3 F o Date
� Contractor e: V
ARCHITECTS DECLARATION
66 1 understand my plans shall be used as public records
jyU
v. y Licensed Professional
6 0.<
OWNER-BUILDER DECLARATION
s 1 hereby .[Than that 1 am exempt from the Contractors License Law for the
y ❑ o following mason. (Section 7031.5, Business and Professions Code: Any city or county
k which requires a permit to construct, alter, improve, demolish, or repair any structure
y y prior to its issuance, also requires the applicant for such permit to file a signed statement
£ G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
y$ (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 live hundred dollars ($500).
❑ I, 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 Contractor's 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 arofCered ror 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.
❑ 1 am exempt under Sec B & P C for this mason
Owner 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-insum for Workers Compen-
sation, as provided for by Section 3700 of the tabor 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.
My Workers Compensation Insurance carrier and Policy num
ram
:
Carrier. �yL�6�/0/ N,P9 _ No.: a r'7
CERTIFICATE OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
1 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
O forthwith comply with such provisions or this permit shall be deemed revoked.
zCONSTRUCTION LENDING AGENCY
rA [� r -r I hereby affirm that there is a construction lending agency for the performance of
fYa 1 the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lender's Name
�z Lander'sAddress
U 0 1 certify that 1 have read this application and state that the above information is
[L ►r correct. l agree to comply with all city and county ordinances and state laws relating to
®V building construction, and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
�q to liabilities, judgments, costs and expenses which may in any way accrue against said City
U 'Z inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG ATIONS.
& I CC
Signature oCApplicant/ ntractor Date
H ARDOUS MATERIALS SCLOSURE
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 Safety
Code, Section 25532(a)?
❑Yes �o
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?
❑Yes tints
1 have mad the hazardous materials requirements under Chapter 6.95 orthe Califor-
nia Health & SafetyCodc, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is
my responsibility to nodry the occupant of the
requirements which t9us mel pr or seance of a Certificate of Occupancy.
Owner or authorizedOwner or agent Date%(�/�C%_Date '
Job Description
REVISION,VAULT FOR BANK,STRUCTURAL CALLS & DETAIL
ORIG#09030059
Ft. Floor
APN Number Occupancy Type
36906010.STE160
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date �f.��y"B �
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 Date
. All roof coverings to be Class',n" or better
PERMIT NO.
PERMIT ISSUE DATE
8 9
A O.
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
Job Description
REVISION,VAULT FOR BANK,STRUCTURAL CALLS & DETAIL
ORIG#09030059
Ft. Floor
APN Number Occupancy Type
36906010.STE160
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date �f.��y"B �
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 Date
. All roof coverings to be Class',n" or better