09050159 CITY OF CUPERTINO ;
BUILDING DIVISION
PERMIT CfiTIAT+C1I� ? IVATI� :
BUILDING ADDRESS: PERMIT NO.
20640 STEVENS CREEK BLVD TBD-- '--'0 BE DETERMINED
'NER'S NAME: PERMIT ISSUE DATE
PHONE: SXNffAi&2 9 9 9 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a O p LICENSED CONTRACTOR'S DECLARATION
mI hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
with So
caon 7000)of Division 3 of the Business and Professions Code,and my license is
�z in full
forces deffet*,5 Iva8o CHANNEL LETTER SIGN
Y Lic.x
q Date Contractor
3W ARCHI7'ECl'S DECLARATI N
Cd V I understand my plans shall be used as public records
o,
O y Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
e which requires a permit to convect alter,improve,demolish,or repair any structure
y Z prior to its issuance,also requires the applicant for such permit to file a signed statement
E_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
s:E- (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 $2000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500)
I,as owner of the 32610060 .4 0
❑ property,a my employees with wages az their soft compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law docs not apply to an owner of Required Inspections
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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors 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 reason
ner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑f have and will maintain a Certificate of Consent to self-insum 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.
❑1 have and will maintain Workers Compensation Insurance,az mquircd by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My WorkeeLCompensation Insurance carrier and Policy number am:
Carrier OL Of VV-RrM&V— Policy No.:WO0 9 SMA 70 t—
CERTIFICATE OF EXEMPTION FROM WORKERS'
�sw•*6 6--c—COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
OF Iess.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so az 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
,J Q forthwith comply with such provisions or this permit shall be deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
E.r rte. 1 hereby affirm that there is a convection lending agency for the performance of
a+ the work for which this permit is issued(Sec.3097,Civ.C.)
W41. Q Lenders Name
a Lenders Address
V C-) I certify that I have read this application and state that the above information is
LL n-n cortccL I agree to comply with all city and county ordinances and stale laws relating to
0 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
to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the grana of this permit.
h"h APPLICANT UNDERST AND WILL COMPLY WITH ALL NON-POI Issued by Date S 2• �
SOURCE REGULATIONS.
2 70 Re-roofs ✓�---�
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
+s defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
de,Section 25532(a)? t,*-„' All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes -� '
Will the applicant or future building occupant use equipment or devices which If a roof i;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505.25533 and 25534.1 understand that if the building
does not c 0y have a tenant,that it is my responsibility to notify the occupant of the
reyuircmc is ich m x t prior to issuance of a Certificate of Occ cr. Signature of Applicant Date
_ a7 o
Owner or a oriz d agent Da All roof coverings to be Class'' `'or better