09050173CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10900 N BLANEY AVE
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER:
u p p LICENSED CONTRACTOR'S DECLARATION
� us r- I hereby aflitm that I am licensed under provisions of Chapter 9 (commencing
= Z w with Section 7000) of Division 3 of the Business and Professions Code and my license is
a ° in full force and effect
j Z License Class Lic. N
F„ Date Contractor
.UJ a ARCHITECTS DEC LARA ON
ia I understand my plans shall be used as public records
3yU
u, H Licensed Professional
n H OWNER -BUILDER DECLARATION
a I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following mason. (Section 7031.5, Business and Professions Code: Any city mr county
R m which requires a permit to concoct, alter, improve, demolish, or repair any structure
a 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
=O
r F- (commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the structure is notintended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
awn 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
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.
❑ I am exempt under Sea , B & P C for this reason
Owner Date _
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
AfI have and will maintain Worker's Compensation Insurance, as required by Section
-3700 of the Labor Code, for the performance of the work for which this permit is issued,
My Worker's Compensation Insurance carrier and Policy number are:
Carrier."We_ Policy No.:_5CLsi;i��fQ 3' —200
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITis section need not be completed if the permit is for one hundred dollars (S10()
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 Worker's Compensation provisions of the tabor Coda you must
2 forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
.-t
I hereby affirm that there is a concoction lending agency for the performance of
.� the work for which this permit is issued (Sec. 3097, Civ. C.)
a 0 Lender's Name
Lender's Address
U Q 1 certify that 1 have read this application and state that the above information is
LL correct I agree to comply with all city and county ordinances and stale laws relating to
0U building construction, and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
to liabilities, judgments, toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTAND ND WILL COMPLY WITH ALL NON -POINT
SOURjZ nr NS, 4 �a 2
Signature mf Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? J
❑ Yes t[I Na
Will the applicant or future building occupant use equipment or devices which
emit harardnus air contaminants as defined by the Bay Area Air Quality Management
District,
C] Yes
.lam Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it ' my responsibility to notify the occupant of the
requirpm9fts w0ich myst be met priissuance of a CertificVc of Occopanry.
Owner or authorized
CB2 BUI
(415)402-0360
PERMIT NO.
ncm-,oi 73
PERMIT LSSUE DATE
n
5 A CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
REMOVE NON COMPLIANT SECTION OF CONCRE'T'E
APPROX. 15X 20 TO INSTALL NEW CONCRETE AT LESS
THAN 2% GRADE. INSTALL TRUNCATED DOMES AT RAMP
Ft. Floor Area
Number
31603045
Issued by:
Re -roofs
Type of Roof
Required Inspections
Valuation
Type
Date ) 2 f _
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.
Signature of Applicant Date
All roof coverings to be Class 'A" or better