09050074FA
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
Q it�'7ATON:
BUILDING ADDRESS:
PERMIT NO.
OWNWl{ 4 I)AME:
PERMIT ISSUE DATE
G 9
PHO
CONTROL NO.
942-8200
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
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in full fate and err
T . I DEMO OF (E) RESTRMS & BUILD -OUT OF ADA
License ClanLic. 0
Dam Z ^Z cor d) P t /(64-7 (Lff4L&--'WTOMPLIANT
ARCHrrEC1-S DECLARXTION
I understand my plans shall be used as public records
RESTRMS , COPY r BREAKRMS , TOUCHDOWN AREAS) NO
STRUCTRL&
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
NO RE—RF (6 % % 2 SQ )
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 dole a signed statement
That he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 0 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption Any violation of
APN Number
Occupancy �+,� e
p y •7 p
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($500�
31622017 1 THRU 4
❑ L as owner of the property, or my employees with wages as their sole compensation,
.
Required Inspections
will do the wort, 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 of
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 sal& If.
however, the building or improvement is sold within one year of completion, the owner -
builder wt71 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 Coutracw 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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations-
0 1 have and will maintain a Certificate of Consent 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 Workers Compensation lnsurance, 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-^ �-
Cartier. �i..J'{1��t4'% jLA(,PolicyNo.: �-^�) % ^2
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dallm (SIOG)
or Icss)
1 Certify that in the performance of the work for which this permit is issued, I shall not
employ arry 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 must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Lenders Name
Lenders Address
1 unify that I have read this application and sure that the above information is
correct. 1 a&= to comply with all city and county ordinances and state Ines relating to
building construction, and hereby authorize 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
liabilities, judgments, costs and expenses which may in any way acrcuc against said City
in consequence of the granting of this permiL
APPLICA UNDERSTANDS A D WILL COMPLY WITH ALL NON -POINT
�SUed by; — _ _ _ _ Date .
SOURCE ULA ONS.
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Re -roofs �✓
Signawk fApplicMVCOnLrac4 IDa
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
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)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ❑-1
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 Quality Management
all new materials for inspection.
Disuict7
❑ Yes ❑Now
1 have read the hazardous materials requirements under Chapter Q95 of theCalifor-
nu Health & Safety Code, Sections 25505.25333 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
mqu ts which must be met im rto Issuance of a certificate of Gceuy�'
Signature of Applicant Date
' Cw�-V� *yam r eJ G/�(.7m
All roof coverings to be Class'%¢.' or better
Owner or authorized agent Datc