09040031CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS;
OWNFfl~&250A
PHO~PPLE
CONTROL O.
408)942-8200
BUILDING PERMITINFOi
BLDG ELECT PLUMB j MECH
ARCHm;:CTIENGlNEER;
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•'" 1= I hercby affinn ,Julllam licensed undcr pmYisions of Chapler 9 (commencing !!i &l willt Sec~on 7000) ofDivision 3 of lite Buainess and Profes.ROIU Code. and my license is
~~e; in.CullfOR:cand.efcecL~ , ...,CG II -~ a~ 2; License CI..~ _ ..' .!....:J...J._.J..L..!-'9=----Lie. It _~<;;::~ Dale f;.J 12d I ARCHm;:ci?;~J'~:-:R::-I\:=T1:::0=:N.,.....------~~< lundcnaand myplalUshall he uscd as puhlic n:conls
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Cu.i-Li....nscdProfessional !:o~ OWNER·BUILDER DECLARATION
• '" oJ I hercby ./Tinn lIta, I am =mpl Crom lite Conlnctor's License Law for lhe~?< ::Ii.0° following "'ason. (Sec~on 7031.3. Business and Profc.";ons Code: Anycily or coonly ~2~which requin:s a pcnnitlO conSUUCL aller, imp""", demolish. or repair any stnlClore u-", prior to i.. issuance..... rcqoin:s lite applicant for such pennillo file a signed slalemen(:!?< thai he islicelUCd pu""anllo lite pmvi.ions of lite Contr.u:lOr', License Law (Chapu:r9~:c 0 ~ i-i (commencing with Sec~on 7000) oC Division 3 of lhc Business and Professions C~) or
Job Description
COMML TI-ADD 2 NEW CONFERENCE RMS AT LOBBY,ADD
NEW
MECHANICAL UNIT@ ROOF REPLACE ALL ACUSTICAL
CEILING TILES&LIGHT FIXTURES THROUGHOUT.
Sq. Ft. Floor Area Valuation
0000
e§: -lItat he ia e..mptlltelCCmm and the basis for the alleged elCmption. Any Yiolation of l-~;-;~~T~;__--------r--->oUOl....Ll<~*~---____;=_--+-----
Section 7031.3 by any applicanl Cor. pennilsuhjects the applicanLlo a civil penally of ' APN Number Occupancy Type
nol more lItan five hundred dollars ($300). 31621089,STE150/250Aa I, as owner oCthe property, or my employees with wages .. their sole compensation, I-----------------....---:---::-::l----------------+----
will do the work.and the .UUClun:i.nol inlended or offered for laic (Sec.7044,Business Required Inspecu'ons
and ProCcs.sions Code: The Contr.u:tor's Liccosc Law docs nol apply to an owner of
propcny who builds or improves thelCOn, and who docs 'uch work himself or through his
own employees, proYided lItat such imp"""ments arc nOI inlended or offered Cor sale. If.
however.lIte building or improvemenl is sold within one year oC comple~on. lite owner-
builder will have lite burden oC proving thaI he did nol build or improve for purpose aC
sale.).
a I. as owner oC lite propeny, am exclusively conlnCling with licelllCd contractors to
construClthe projeCl (Sec. 7044. Business and ProCcs.sions Code:) The ConlnClOr's Li
CCIIIC Law docs nOlapply to an owner of propcny who builds or improves thereon, and .
who contnlcts for such pmjects with a cantr.u:IOr(.) IicclIICd pu....antlO the ConlnClor's
Lil:cnsc Law. a I am exempl under Sec. • B & PC Cor litis lCISOII
Owner Dale _
WORKER'S COMPENSATION DECURATION
1 hcrcby affirm under penally oC perjury one oC the Collowing declarations:
a I ha'" and will maintain a Ccnificale oCConsentlo self·insure Cor Wor1o:r's Compen
sation. as provided Cor by Section 3700 oC the Labor Code, for the pedonnan.. oC lhc
work for which lItia pennil is iasocd.
a I have and will maintain Worker's Compensation IlISIII3IIce, as mquired by Section
3700 of the Labor Code. Cor the pedormance oC the work for which this pennil is i....d.
My Wor~.Compe~on Insurance carriel and Policy number ~.~fl)
Carrier. ZZ--, fl c..Vi 4 ..1.1 y, (~olicy NO.:_~~=--(;.;.-"1!::.
CERT1ACATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thia seclio. need nol he campleled iC lhc pennil is for one hundred doll... ($100)
or Ie...)
I certiCy thaI in the pcrConnancc oC the work for which this pennil ia issued, I .hall "01
employ any pc ..on in any manner so as to hecome subjecl'o the Workers' CornpelUatianLaws of California. Dale _
Applicanl __---=-=---------=---------
NOTICE TO APPUCANT: If. an.r malting lItia Ccnilicole oC Exemption, you should
become .uhjeClIo the Wor1o:r's Compcnlitian provisions of the Labor Code, you mllSl
forthwith comply with such provisions or dais pcrmiL shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hercby affinn thaI there ia a consuuction lending agency for the performance uf
the work for which this pennil is issued (Sec. 3097, Civ. C.)Lender'. Name -----_
Lender'sAddn:ss _
I ccniCy thaI I have read this applicstion and '1I1e that the above infonnation ia
correct. 1 agn:c to comply with all oily and counlY onlinances and slllC laws lClating to
building consuucLion, and hereby IUthOrilJ: rcpn:scnlauves of this chy to enlCr upnn the
above·mentioned pmpeny for inspection porposes.
(We) Igree 10 save. indemnify and keep harmless the Cily oC Cupcrtino agailUl
liabilities, judgments. cos.. and expenses which may in any way accrue againsl said Cily
in consequence of the grantinl of this pcrmiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON·POINT
SOURC~jSJULA1JONS. \ \ Iz
(, c~ ~.~ ~OC'}C-5 ~l JcdSilnaturCfAPplicanliContr.u:~\ ' Dat
HAZARDOUS MATERIALS DISCLOSURE
Wiflthe applicant or fUlUre building aceupanl storc Or handle hazardous malerial
as defined by lite Cupertino Municipal Code. Chapler 9.12. and the Health and Safety
Code. Section 23332(1)1 ____
ayes E::1No
Will thc applicanl or futUlC building occupant usc equipmenl or devices which
emil ha7.ardous air conwninanlS as defined by lhc Bay Area Air Qualily Managemc:nl
District? ~
ayes DNo
fJiiifij
J
Issued by: Date
f------=---=~..J-::;:_-r~-=-=-==----------------
Re-roofs
'TYpe of Roof
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.
I have read the hazardous m...rials ",quilCm.nts undcrChapter6.9S oClhc Califor·
nia Health & Safely Code, Sections 23503, 23533 and 25334.1 undcrs""'d lhal iflhc building
docs nOI cu""nlly ha.. 1 1<JlIIIL th.1 il ia my rcsponsihilily 10 notify lhc aceupanl of lhc
rcqui",m.n~ which mllSl he mel p 'or 10 issoance of a Certifica.. oCOccl!Pancy. Signature of Applicant Date
Owner or authori7.cd agcnl
" -·.v..--f '-'--0C< 5 2. 0
ate -All roof coverings to be Class ''It'' or better