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CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
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BUILDING ADDRESS:
PERMIT NO.
20400 STEVENS CREEK 'RLVD STR
NOVO CONSTRUCTION
OW NT1RI U —mf-4 O
PERMTT ISSUE DATE
PHO .
S A CONTROL NO.
(650)701-1500
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
.lob
with Section 70W) of Division 3 of the Business and Professium Code, and my license is
in full force andcllc5t
COMML TI INTER ONLY NON-STRCTRL MECH/ELEC/PLMBNG
License Class-� Llc. M
Date LN --', "!� Contractor i,,l C' sin e r t:-.7y
2 8 0 0 SQFT
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby aff rm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's Uc== Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 0 O O 0 O
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031 J by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (3500).
36901028 STE130
❑ I, p petty, or my employes with wages as their sole compensation,
as owner of trio property,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The ConnwuWs License Law dolts not apply to an owner of
property who builds orimproves 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
tale.),
❑ L as owner of the property, am =elusively contracting with licensed cuntractors to
construct the project (Sec. 7044, Business and Professions Code:) The Conuacwrs Li-
censc 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 Contractors
License Law-
0 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION 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 Workers Compen-
sation, as provided for by Section 3700 of the Labor Cade, 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 Workers Compensation Insurance nor and Policy number are:
,e�}
Carer 4� i��uc%Pu.�t/ Policy No.:
CERTIFICATE OF IX PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars ($100)
or less)
I certify 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 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 Workers Compensation provisions of the Labor Code, you mum
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is aconstruction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
'
Landers Name
Lenders Address
I certify that I have read this application and state that the above information is
'
Comet I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise 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
liabilWca,judgments, casts and expenses which may in any way accrue against said City
in consequence of the granting of this permit.Y✓�
iy.'LU7t[QERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU REGULATI.O!•(S. �}
Re -roofs
Type of Roof
iAPPLIC
__-.
signitureafjkpplicazWCont9kior Date
HAZOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstom or handle hazatdons material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section25532(a)?
❑ Yes
oIf
All roofs shall be inspected prior to any roofing material being installed.
ruturc
a roof is installed without first obtaining an inspection, I agree to remove
Will dre applicant or 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
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth &SafctyCode, Sections 25505,25533and 25534.1understand that ifthe building
does not currently have a tenant. that It is my responsibility to notify the occupant of the
ttirpmrnts wife nst hem ores, tartce ara Ccnirtr�oITOc�p�aw
Signature of Applicant Date
All roof coverings to be Class or better
wncr or au hor .cd agent