09060009CITY OF CUPERTINO 7�
BUILDING DIVISION PERMIT
7�7
BUILDING ADDRESS:
PERMIT NO.
19620 STEVENS CREEK BLVD #180
GREATWALL BLDG CONTRACTOR
0906.0009
OWNER'S NAME:
INC
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO.
(510) 589-7528
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Divisign 3 of the Business and P fessions Code, and any license is
in full force and effect s ��
REVISE:MECHANICAL ROOF TOP DUCT WORK DETAIL
'
License Claz
Date Contractor
04
ORIGINAL # 08090177—NO NEW PERMIT
ARC CTS DECL.AR 1
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby ol7irm that 1 am exempt from the Contractors 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
prior to its issuance, also requires the applicant for such permit to file a signed statement
the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
4 O O O
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
36906010 .170/180
❑ I, as owner. of the property, or my employees with wages as their sole compensation,
Required Inspections
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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Conlracmrs 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
WORKER'S COMPENSATION DECLARATION
1 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 bar ode, for the perform ce of the work for which this permit is issued,
'
My Worker' o nsadoo nsurance Tier and Policy number are: a
Cartier. �i nl qc Policy No.;
CERTIFICATE OF E EM1z170N FROM ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
'
or less.)
I cal that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so az to become subject to the Workers' Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If, atter 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 lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Lenders 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 properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabiltties,judgmenls,costs and expenses which may in any way accrue against said City
in consequent of the granting of this permit.
APPLICA NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC E UL IONS.
Re -roofs
Type of Roof
Signature a pplicant/Contraclor �� Dat
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 Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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 de od by the Bay Area Air Quality Management
all new materials for Inspection.
District?
❑Yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Cal Il
nia Health & Safely Code, Sections 25 505, 25533 and 25534.1 understand that if the building
docs not curtentiy ve a levan that it is my responsibility to notify the occupant or the
does
tcnis
c whi ust be mel prierto i ee ora eenifieam orOceapane .
Signature of Applicant Date
— 61
All roof coverings to be Class or or better
—y Date
Owncrorauthorizcdagcnl