09050165 77777777777777-1...
CITE'OF CUPERTINO
BUILDING DIVISION PERMIT � � �`�� '
PERMIT NO.
BUILDING ADDRESS:
19925 STEVENS CREEK BLVD DEVCON CONSTRUCTION INC 09050165
JE 2 5 OA PERMrr ISSUE DATE
APPLE
SA AR CONTROL NO.
PHONE:
(408) 94:2-8200
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0 0
a p LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 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 REV,ADI) 2 OFC ' S ON 2ND FLR, RE-WORK 2 O F C S INTO 3
yin full force and effect.
License Class Lic.x OFCS ON 2ND FLR& ADD LIGHT FIXTURES ON 1ST&2ND
t-a Date Contractor
ARCHITECTS DECLARATION FLR;OR-'G #09040031
tt -CI understand my plans shall be used as public records
jut
u.y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
0 o following reason.(Section 703 1.5,Business and Professions Code:Any city or county
m which requires a permit to construct.alter,improve,demolish,or repair any swetum
y-y prior to its issuance,also requires the applicant for such permit to file a signed statementSq Ft.Floor Area Valuation
-z< 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 $0
y 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 mere than five hundred dollars(s500). 316 210 f 3 9 .S T E 15 0/2 5 O A
❑I,u owner of ttie 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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thertwn,and who does such work himself or through his
own employees,provided that such improvements arc 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
sakJ.
as
owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contract0es U-
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.
r-1 I am eatyrap under Sec. B&P C for this reason
ner Date-`=?L LCJ
WORKER' 0 PEN ATION 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 Workees 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.
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 for one hundred dollars(S 100)
or Ices)
1 cenifv 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 sc to the o Compensation
Laws of Cali nate C +��
Applicant
? Q-- 1
NOTICE Td APPLICANT.If,after makin this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z�4 CONSTRUCTION LENDING AGENCY
E^'t rte.. I hereby affirm that Utero is a construction lending agency for the performance of
tY+> the work for whic14
this permi(is i��s(pr��d(S 3097 Civ.
W Q Lender's Name Zt�Y CY'i M15 V l CC-I,,,,-
0,
Z Landees Address
I certify that I have read this application and state that the above information is
U
0 cone.I agree a comply with all city and county ordinances and state laws relating a
0 V building construction,and hereby authorize representatives of Otis city to enter upon rho
above-mentioned property for inspection purposes
>a (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 a
V 7--, in consequence of the granting of this permit. Date-5, L V d
►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR ULAM NS.
Ica c-P o Re-roofs
Signature of Applicant/Conuwtor Date 'j of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
dc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
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 ❑No
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 ratify the occupant of the
reqs; is which nst be i 'r a issuance of a Certificate of Npaner Signatuit of Applicant Date
( �. I c-, - k, C'' All roof coverings to be Class';W'or better
Owner or authorized agent N V Date