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CITY OFCUPERTINO�eitaj'
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMrr NO.
19750 STEVENS CRFFK RT,VD
TBD -
OWNER'S NAME:
PERMrr LSUE DATE
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CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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I herby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, cud my Ikrense is
infull force and effect- lo %295�P1
TWO TEMP GENRTR FOR PG&E SHUTDOWN@ LOADNG DOCK
License Clan IJc. N
Date �/ �� tractor
AREA
R Hi.fECT3 RATION
I understand my plans shall be used as public records
Licensed Professional
OWNER-BUILDIER DECLARATION
1 hereby at inn that 1 am exempt from the Contranm s License Law for the
following mason. (Section 7031-5, Business and Professions Coder My city or county
which requires a permit to construct, alter• improve. demolWt, or repair my structure
prior to its Luuv= also requires the Applicant for such permit to file a signed stalemcni
Contractor's License Law (Chapter 9
Sq. Ft, Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
4 O O O
that he is exranp therefrom and the basis for the alleged asempdon Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects aim applicant to a civil penalty of
not more than Toe hundred dollars ($5W).
36906008.00
❑ L uowner of tits property. or my employees with wags u their sake compensation,
Required Inspections
will do the work, and the structure is riot intended or offered for sale (Set- 7044, Business
and Professions Code: The Contractor's Cleave Las does not apply to an owner of
property who builds or improves thereon, and who does such work himself or th ough his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is said within am year of emmplaion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
SLIP_).
L as Owner of the property. am exclusively contracting with licensed contractors to
cortatroct the project (Sec. 7044. Business and Professimu Coda) The Cw= mr 3 Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contacts for such projects with a conuacter(s) licensed purmanl to the Conuaetot's
License Law.
❑ 1 am exempt under See B R P C for Wla reason
owner Date
WORKERS 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-husum 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 lanwance, as required by Section
.
3700 of the Labor Code, for the performance of the work for which this permit is lasted.
My Worker'{ Compmsadas/lawanc •carrier and Policy n her are:
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3
Gorier, /P'71 �-LTC..-i Policy No.:
'� CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed If the permit is for one hundred dollars ($10D
or IML)
1 certify Ibat in the performamo 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. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you amid
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
I
CONmucnON LENDING AGENCY
1 hereby affirm that there is a constructia lending agency for the performance of
the work for which this permit is issued (Sere. 3097, Civ. C)
'
Lender's Name
Lender's Address
I I certify that I have read this application and state that the above Information is
comet I agtm to comply with all city and county ordinances and state laws misting to
t building construction, and hereby anthoria 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
j liabilities, judgments, costs and expenses which may in arty way accrue against said City
' in consequence of the granting of this permit
i APPLICANT UNDERSTANDS AND WILL COMPLY wrp ALL NON -POINT
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Issued by: Date
SOUR TIp 2 O
/
Re -roofs
Type of Roof
Sig&Lurc of AppliesnUConuactor Dam
HAZARDOUS MATERIALS DISCLOSURE
WIB the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)? �+a
All roofs shall be inspected prior to any roofing material being installed.
0 Yea
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building pant use equipment or devices which
emit hazardous air contaminants as tier y uK Bay Area Air Quality Manal ement
all new materials for inspection.
District?
Yes No
l have read the hazardous mmcnals rcquircmenu under Chapter 6.95 of the Califor-
nia health de Safety Codr, Sections 25305. 23533 and 25534.1 understand that d the building
d00.t not to�hsaw nxponsilsility te ratify sine occantofthe
rcqu' rtce of a Certificate of Occupany.
Signature of Applicant Date
All roof coverings to be Class'n'' or better
own errDate