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09040162�oaCC �FK u'v ho. qnq — YpC C z.. CTTY OF CUPERTINO � z BUILDING DIVISION PERNHT E 3r BUILDING ADDRESS: PERMIT NO. 11111 N WOLFF RD STE C TBD — OWNER'S NAME: PERMIT ISSUE DATE PFiO CONTROL NO. ARCFITECuENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions or Chapter 9 (commencing with Section 70W) of Division 3 of the Business and Professions Codo y license is and cffccL ff ADD 1 MICROWAVE & UNDERCOUNTER REFRIGERATOR. infur�lf clazi Date cnmuactor ELECTRICAL & MECHANICAL. ARCHITECTS DECLA TIO I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following mason. (Section 70313, 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 m rule a signed statement Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 0 that he is exempt therefrom and the basis for the alleged exemption Any violation of APN Number Occupancy Type p �' yp Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of not mac than five hundred dollars (S500) 316 0 5 0 7 2 . S TEC ❑ L as owner or the property, a my employees with wages as weir sole compensation. Required Inspections will do the wodL and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner or property who builds or improves thereon, and who does such work hiruself or through his own employees, 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 proving that he did not build or improve for purpose of sac.). ❑ 1. as owner of the property, am exclusively contracting with Eceneed contractors to constroct the project (Sec 7044. Business and Professions Code:) The Contractors Li- ccnw Law does not apply to in owner of property who builds or improves thereon. and . who contracts for such projects with a contractea(s) licensed pursuant to the Contractors Lice= Live. ❑ 1 am exempt under Sec B R P C for this mason Owner Date WORKERS COMPENSATION DECLARATION 1 hereby aQtrm tinder penalty of pesjury one of the following declarations ❑ 1 haft and will maintain a Certificate of Conwnnt to self -Insure 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 ❑ I have and will maintain Wasters Compensation Insurance, as required by Section 3700 or the Labor Code• for the performance of the work for which this permit is issued My Wo Com enaction ass ce aocr and Policy number are: _ r Carder. t Polley No.: CE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if we permit Is for one hundred dollars ($100) or less.) 1 certify that in the performaoce 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 Wakcts' Compensation Laws of California. Date AppLiant NOTICE TO APPLICANT: If, aft making this Certificate of ExLmption, you should become subject to the Workers Compcnstition provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be doomed rooked. 1 CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Scc 3097, Civ. C.) Lenders Name Landers Address j I certify that I have read this application and state than the show information is cm=L 1 agree to comply with all city and county ordinances and state laws misting to ' building construction, and hereby mworixe representatives of this city to eater upon the above -mentioned property for Inspection purposes (We) a cave indemnify ad keep harmless the City of Cupertino against liabilities,jod ,costs and expense= which may in arty way acaue.gsinn said City APM the granting of this permll APPL]CkAyll DERSTANDS A D WILL COMPLY WITH OLL V6N-P0iNT Issued by: Date Jf / SOU G TT n (/ Re -roofs �Y Type of Roof Si6wari,6f ppsanuc°n Doc HAZARDOUS MATERIALS Dls WII the applicant or future building occupant store or handle hazardous maerial as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety Code, section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑ Yes a roof is installed without first obtaining an inspection, I agree to remove Will the applicant a forum building occupant use equipment or devices which emit hazardous air contaminants as dc0ned by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes �Nu 1 have materials requirements under Chapter &95 of the Califor- nfalicalthdcS Y Scctiats2550.S,25533snd25534.1usdcrJtaru�dwifdzdaa note ha a tenon, ttnat h is m responsihility n ndlfy dereq°ire '`h met 'ors °r' 11eO Signature of Applicant Date All roof coverings to be Class's" or better Ow authorvedagem'Elate .