09060062 CITY OF CUPERTINO A
BUILDING DIVISION PERMIT � � � �
BUILDING ADDRESS: PERMIT NO.
10212 N DE ANZA BLVD BENCHMARK COkLSI�I �� 09060062
PERMIT ISSUE DATE
^WNER'S NAME.
I L1212 -N DE1, VISTA AVE Ak A O. 9 9 9 CONTROL NO.
PHONE:
(650) 938-1802
BUILDING PERMIT INFO
ARCHrECTIENGINEER:
BLDG ELECT PLUMB MECH
0 0 a a
u c a LICENSED CONTRACTOR'S DECLARATION Job Description
ul p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z, with Section 7000)of Division 3 of the Business and Professions Code.and my license is DEMO CCM'L BLDG(2 8 6 4 S Q)
in full force and effect
? License Class Lle•N
' DateContractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
D96U
L o,I- Licensed Professional
y 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 703 1.5,Business and Pmfessions Cc&:Any city or county
K 8! which requires a permit to construct.alter,improve,demolish,or repair any structure
u Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
xH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5000
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 APN Number Occupancy Type
not more than five hundred dollars(M). 316 2 6 0 F 8 . 00
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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,die 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
o construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
C]I am exem under Sec ,B&P C t this n
`canerECLADate
WORK S C SATION DRATION
hereby affirm 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.
❑I 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 ate:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
or less.)
I certify that in the performance of wo for whicIt this permit is issued,I shall not
employ any person in any mann O If^bject to the W rrkcrs'Compensation
Laws of Califoryil.Date (((PPPAAA////// '
Applicant --r i o) MeAMMVZ E3
-
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z'' CONSTRUCTION LENDING AGENCY
[~i 4 I hereby affirm that there is a construction lending agency for the performance of
p+> the work for which this permit is issued(Sec.3097.Civ.C.)
QLendces Name
Z L.ende's Address
U 0 I certify that 1 have read this application and state that the above information is
LL O- correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
a, (We)agree to save,indemnify and keep harmless the City of Cupertino against
�t� liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in conseq cc of the granting of this permit. Date
-- APPLI UNDER DS AND WILL COMPLY WITH ALL ON- OINT Issued b�:
SOU REGULA
D Re-roof,
Si rare car ppli o tar te T Of Roof
MATERIALS DISCLOSURE Type
10 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
^ode.Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
❑Yes
he applicant future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
Will t
emit hazardous air contaminants as defined by the Bay Area Air Quality Manascmcnt all new 1 naterials for inspection.
District?
❑Yes No
I 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 is my responsibility to notify the occupant of
requirements which must be met ' rto issuance of Certificate of Occu a . Signature.of Applicant Date
2 11�- All roof coverings to be Class"Jt,"'or better
Ovkher or authorized agent