09060166 CITY OF CUPERTINO
BUMDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
19929 S•TEVEN8 CREEK BLVD TBD — TO BE DETERMINED
OWNER'S NAME: PERMIT ISSUE DATE
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION fob Description
U(= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
HOOK—UF PLUMBING/ELECTRICAL
y in full force and effect
D12Z License Class Lic.k
3!: Date Contractor
ARCHITECTS DECLARATION
ooh< 1 understand my plans shall be used as public records
�yU
LO y Licensed Professional
n
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
R2.9 which requires a permit to concoct alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
=a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 SQ.Ft.Floor Area
Y.t–$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1500
y 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 five hundred dollars(5500)_ 316 210 S 0 . 00
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for safe(Sec.7044,Business Required Inspections
and Professions Code:The Contmetoes 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 wt ve the burden of proving that he did not build or improve for purpose of
safe.). V,.,s;ati chi
as owner of the W;oparer am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
0 1 am ex pu Qdar6 B&PCF this n
Owner Dam
RAS 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 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.
0 I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE 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 sou ty�aaalay311�ject to the Workers'Compensation
Laws of California.D �—
Applicant
NOTICE TO APPLICA m n is eralficate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
ZZ CONSTRUCTION LENDING AGENCY
i
1 hereby affirm that there is a constnrction lending agency for the performance of
p:> the work for which this permit is issued(Sec.3097,Civ.C.)
a Q Lender's Name
Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
LL r"r correct I agree to comply with all city and county ordinances and state laws relating to
0 V building concoction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
rF.t to liabilities,judgments,costs and expenses which may in any way accmc against said City
V Z in consequence of the granting of this permit. Date
�" APPLICANT U RS WILL COMPLY WITH ALL NON-POINT Issued b)
SOURCE R A 4 ��
Re-roofs
Signature o pplicant/ r Dale T of Roof
MATERIALS DISCLOSURE Type
Will the applicant or future building L store or handle hazardous material
as defined by the Cupertino Municipal e.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes o
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
A hazardous air contaminants as dcfi y the Bay Area Air Quality Management all new r iaterials for inspection.
✓istrict?
0 Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 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
requi metpriortoissuanccoCaCenificateo� 25 Signaturf:ofApplicant Date
lV�✓f All roof coverings to be Class'n"or better
O Date