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CITY OF CUPERTINO
PERMIT�rRR�icrQlt
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
nWNER'S NAME:
INC
PERMIT ISSUE DATE
PHO
S A CONTROL NO.
(408)379-5500
ARCHITECTIENGINEER:
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 D" 'cion 3 of the Business and Professions Codc, apt my license is
infullforceandeffect. -�
UPGRADE DEVELPER RELATIONS BRIEFING CENTER, NEW
License C ► �• N
Date Contractor
CARPET, PLASMA SCREEN, SERVER ROOM, CEILING
RCHITECCS DECLARA O
1 understand my plans shall be used at public records
TILES,
NEW DOORS, PAINT, AND CABINETS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
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
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to rile a signed statement
Law 9
i that he is licensed pursuant to the previsions of the Contractor's License (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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 fire hundred dollars (M).
31602105 .00
❑ 1, as owner of the property. or my employees with wages as their sole compensation,
Required Inspections
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will do the work, and the structure is not intended 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
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.).
[-11. 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 contractor(s) licensed pursuant to the Contractor's
License law.
❑ I am exempt under Sec . B & P C for this reason
'owner 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 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 Compens ion Insurance carrier and Policy number arc:
Cartier.JJAAC- Policy
RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ 100)
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. Dau
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 must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction (ending agency for the performance of
~ the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read 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
(W to save, indemnify and keep harmless the City of Cupertino against
nliabiliti , judgm , coss and expenses ich may in any accrue against said City
%
7 in co quenec the granting of this
APP (CANT ERSTANDS A LL CO PLY WITH ALL ON- OINT
Date
Issued by: ( l
So CE REG NS.
1
J
Re -roofs
Type of F.00f
Sign icant/Contractor Da
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
^ode, Section 25532(a)?. --
All roofs shall be inspected prior to any roofing material being installed.
1;k
C] Yes 1;(1 No
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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.
District? i./A
❑ Yes L21 tvu
1 have the harardcw``s maaterials requirements under Chapter 6.95 of the Califor-
nice Health of Code. Sections 25505, 25 and 25534. I understand that. the building
docs not rren y have a tenant, stat i ponsibilit to notify theup of the
c fheatc
Date
reyuirc nus which m st be met prio i ce ora or N ��.
Signature o Applicant
U
All roof coverings to be Class"A" or better
Owner r autho d agent Date