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09050014r� CITY OF CUPERTINO � BUILDING DIVISION PERMIT � .L.¢`5 Y,'v'.i L.. <'<g. v t fw BUILDING ADDRESS: PERMIT NO. 20400 MARIANI AVE XL CONSTRUCTION OWNER'S NAME: PERMIT ISSUE DATE PHONE: S A CONTROL NO. (408)271-2425 ARCHITECT/ENGINEER: BURRING PERMrTINFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby Affirm that I am lizartsed under provisions of chapter 9 (commencing w{m� riaon3atmeBuvnsandProressiona c,andmylicensca �m0ffect LANDSCAPE, HARDSCAPE @ COURTYARD License Lic. s . Date CO.n CHrrECTs DECLARATION 1 understand my plans shall be used as public records ULc=d Professional OWNER-BURRER DECLARATION I hereby affirm that 1 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 conauuc4 alter. improve, demolish- or repair any structure prior to its issuance. also requires the applicant for such permit to file a signed statement mat he is licensed pursuant to the provisions of the Contractors Uccrtm Law (Chapter 9 Sq. Ft. Floor Area Valuation (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. Arty violation or 2 5 0 0 0 0 APN Number Occupancy Type P y yes Section 7031.5 by any, applicant for a permit subjects the applicant to a civil penalty of re mam not moan five hundred doll(3500). 31622018 .00 ❑ L as owner of the property. or my employees with wag= as their sole compertudon, Required Inspections will do the work, and the su=um Is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Conuaelors License Law does not apply to an owner of property who builds or improves mccon, and who does such wort himself or through his we 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 haw the burden of proving that he did not build or improve for purpose of sakJ. ❑ L as owner of the property, am exclusively contracting with licensed contractors to construct tie project (Sec 7044, Business and Professions Code:) The Conuactur's U- cease Law does not apply to an owner of property who builds or improves thermos and who contracts for such projects with a contractor(s) licensed pursuant to the Conuacrors Lice rise Law- ❑ 1 am exempt under Sec , B & P C for this mason owner Date WORKER'S COMPENSA77ON DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compcn sation, as provided for by Section 3700 of the Labor Code, for the performance of the wort for which this permit is issued ❑ I have and will maintain Worker's Compensation lost rang, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is Issued, ' My Wor �s,�C,� ypep�en`�ta_�ionJJ����rnrssu��nnccarrier yan�d Policy number Cartier����'atdf\ Vvl�Vrs.�vlonsv No.: CERTIFICATE OF EXEMPI70N FROM OR) S' COMPENSATION INSURANCE (ribs section treed not be completed If the permit is for one hundred dollars ($100) or lea) I certify that In the performance of the work for which this permit is issued, I awl not employ any person in any manner so as to become subject to the Workers' ComptMadon Laws of Caliremla 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 most forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a cononrction lending agency nor the performance of die work for which this permit is issued (Sec. 3097, Civ, C.) Lender's Name , Lenders Address I certify that I have read this application and state that the above Information is con'= 1 agree to comply with all city and county ordinances and state laws relating to building construction. and bemby author m representatives of this city to enter upon the above -mentioned property ror 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 accrue against said City inconsequence of the gran ng of this perrniL 7 _ APPLI ANT UNDER NDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date l s0 EGU Re roofs Type of Roof 4 Signature o App an HAZARDOUS MATERIALS DlscLosuRE Will the applicant or future building occupant store or handle haardous material as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety Code, o 25532(a)7 All roofs shall be inspected prior to any roofing material being installed. esos Noto 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? ❑ Yes LP o I have mad the hazardous marcrfaLs requirements under Chapter 6.95 of the Cali ror- nia Health & Sarcty Codc, ScNnrts 5W, 25533 oral 25534.1 urAcMand that if thc building does not currently have a rrnant, at It is my responsibility to notify the occupant of the ts which rut be et nor to M a Certificate or Signature of Applicant Date All roof coverings to be Class in" or better Owner or authorized agent D