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CITY OF CUPERTINO
DIVISION PERMIT
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BUILDING
BUILDING ADDRESS:
PERMIT NO.
10121 N. FOOTHILL BLVD
TBD - TO BE DETERMINED
09050133
^W NER'S NAME:
MTTZ ITl
PERMrr ISSUE DATE
PHONE:
SAMfA CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I 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
in full forceandeffect.
PHASE II EVR UPGRADES ISD INSTLLATION VEEDER ROOT
737
LicenseCass�{ 2— conLr
Date Contractor
CARBON CANISTER - CAL -PHASE CONSTRUCTION, INC. PD
ARCHrmcrS DECLARATION C d (� J j
BUS LIC
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, 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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$15000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
342 3 2 070
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
e nse
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: ThConuactoes 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, 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 Li.
cense Law does not apply to an owner of property who builds or improves themon, and.
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under See. B & P C for this mason
`caner 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 Workces 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 dee Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number ate:
Carrier. J� ffi % Cl L.ij I) Policy No.: al 7 0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or Ices.)
1 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 Labor Code, you mast
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
i the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
j I certify that I have toad this application and state that the above information is
correct I agree to comply with all city and county ordinances and state laws 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
l liabilities,judgments, costs and expenses which may in any way scenic against said City
in consequence of the granting of this permit.
APPLICANT
HAZARDOUS MATERI D OSURE
Type of Roof
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)?
❑Yes )4, No
All roofs shall be inspected prior to any roofing material being installed.
If a roof i 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.
District?
❑ Yes KN.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand" if the building
does not currently have a tenant, that it is my mspo ibility to notify the occupant of the
mquircmcros ' Certificate of compo .
Signature of Applicant Date
All roof coverings to be Class' j4`' or better
Owner or authorized agent Dare