09050068CITY OF CUPERTINO
BUILDING DIVISION PERNIIT�.
x�
BUILDING ADDRESS:
PERMrr NO.
20813 STEVENS CREEK BLVD
TBD — TO BE DETERMINED
09050068
OWNER'S NAME:
PERMIT ISSUE DATE
PHO�Fc cur
S CONTROL NO.
ARCHITECI7ENCINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o a o a
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am lieu under provisions of Chapter 9 (commencing
with Section 7000) al Division 3 of the Business and Professions Code. and my license is
in full forceana C'%
CLOSE OFF DOOR TO SEP SUITE 100 INTO TWO SUITES
�.?Q3G
Dad contractor +w +t .
(10 0 & 15 0 )
ARCHrTT=S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER-BUBDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Section 7031.5, Business and Processions Code: Any city or county
which requires a permit Lo construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires die applicant for such permit to file a signed slits ment
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Station 7000) of Division 3 of de Business and Professions Code) or
0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation or
5
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty or
APN Number
Occupancy
1)anc Y Type
not more than five hundred dollars (53001
32632052.00
❑ L u owner of the property, or my employees with wages u their sole cmnpensadon,
Required Inspections
will do the worm and the structure 1s rat intended or offered for ale (See_ 7044, Business
and Professions Code: The Contractors Lice is Law dots not appiy to in owner of
property who builds or improves thereon. and who does amch wort hrmself fir through his
awn a nployeea, provided that such improvements are not intended or offered for ale. If.
however, the building or Improvement is sold within one year of completion, the owner -
builder will have the burden of pmAng that he did not bald or improve for purpose of
laical•
❑ L as owner of the prepeny. am exclusively contracting with licensed contractors to
consboa to pmjea (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law don not apply to an owner of property who builds or Improves demon. and .
who contracts for such projects with a contractor(s) licensed purmant to the Contractors
L.Iceme Law_
❑ 1 am exempt under See , B & P C for this reason
owner Date
WORKERS COMPENSA77ON DECLARATION
I hereby aalrm order penalty of perjury one of the following declarations
❑ 1 brae and will maintain a Certificate of Concur to self-Insum for worker's Compen-
sadoe, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
jjKhavc and will mxinWn Worker's Compensation Insurance, as required by Section
3700 of the Labor Codo, for the performance or the worts for which this permit is issued
My Worker's o on In-surJm artier and Policy num�berrare:
Carrier-. U/ Policy No.l bnu;&,A7 2^T
CERTIFICATE OF EXEMPTION FROM WORKERS -
COMPENSArION INSURANCE
(this section need rat be completed if the pemnit Ls for one hundred dollars (S 1 00)
or lest)
I Certify flat In the perform&= of the wort for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Wo kcri Compensation
Lawn of California. Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Wortzes Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shall be deemed mvokcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a corurtsction lending agency for to performance of
Lite work for which this permit is issued (Sec. 3097, Civ. C.)
[vender's Name
L finder's Address
I certify that I have read this application and sate that the shove wormatio n is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agene to save, irtdemnify Lod keep harmless the City of Cupertino against
iiabilities, judgmertu, costa and expenses which may in any way acme against said City
sequcnce of thhe grant permCA UNDEXT 14 S WILL COMPLY WITH All. NON -POINT
Issued by: Date
]APO
9
O
Re -roofs
Type of Roof
n ofAppB ntrDale
HAZARDOUS MATERIALS DISCLOSURE
Will dro xppliantor future building otzupantarore or handle hazardous materixi
asdefined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ;Iwo
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 Qualily Management
all new materials for inspection.
Dittrict7
❑ Yes
I have read the hazard i,v materials requirements under (]apw&95 of the Califor-
nia Health & yCodcS=9Mu25505.25533amIZ5534.lwWm3wWthKifLhe building
W-vt hoe a a t is my responsibility to notify the ocnrpmt of the
hmust t " to nuance ofa C orate o Occupancy.Signature
of Applicant Date
;g-.,.u1_h.-.
All roof coverings to be Class '%�." or better
agent Dare