09050161I
CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
OWNER'S NAME:
PERMIT
COl'ITROL NO,
ARCHITECTIENGlNEER: BUILDING PERMIT INFO
BLDG ELECT PL.UMB MECH
" 00: Zo L----,r;;::;~~r;:;;;:n:ilAM:;w~~""iVm:;;:J----_+------------------:--L--.b1 =:!.I__bl =LI__bl =[1_--1I=,dI_'LICENSED COmRACTOR'S DECLARATION
: OJ l=!?i &l I hereby aflinn thai I am licensed under provisions o( ChaplU 9 (commoncing
with Section 7000) o(Divi.<ion 3 o(!be Busin= and Pro(=ion. Code, and my Iiccnse i.
Job Description
~~e;!i:l2"
;;:@:,51 ::j
in,(UII(ort:<and~_1 ''''''7'' ~~ L,cense C1,.. Lie. # .6 "? .k!7.rl-:_"-.:--.-,-
Dale ~--= dl59.' CoolrarlOr ~& uli'BtN5
ARCHrrncrS DECLARATION
COMMERCIAL T. 1. INTERIOR ONLY 2 1 7 56 I
i ~ ~ I undcnland my plan ••hall be used as public n:cords
: .. I
0'" ~:5
-e:l< 00 :il!l:
Licensed Profe.sional
OWNER-BUILDER DECLARATION
I bereby .fIinn Ibal I am exempl (rom lbc COnIraCIOr'. Liccnse Law (or the
(ollowing reason. (Section 7031.5, Busines. and Pro(=ions Colic: Any cily or counly
which requires a pennit to construct., alter. improve. dcmoIL~h.. or repair any structure
-",
Z>i~ ~!!
prior La iLS issuance. also requires l.hc applicant for such permit to file a signed SLalCmcnl
that he is licensed pursuant La Lhe provisions or the ConlraClOr'S License Law (Chapler 9
(commencing wilb Section 7(00) of Division 3 o( the Business and Pro(essions C~e) or
thai he is exempl therefrom and !be basis (or the alleged eaemption. Any violation o(
Sq. Ft. Floor Area
1 0 0 00 0
Valuation
~_ml~~q_~ba~~~~!be~~~a~~~~~------~M~~N~N~u:m~b:e:r~------~~-~~~~~O~----~~--~----
nOI man: Iban nve hundred dollars (S500). , ccupancy TYpe
D I. as owner o( the property, or my employees with wages as their sole com~nsation, 32 61 0060 . 40
will do Ibe wor1<. and the struclu", i. nOlintended orofTered (or.ale (Sec:. 7044, Business r-----------------:::-----:---:-=------------------------
and Pro(essions Code: The ConlraClDr's Uccnse Law docs nol apply 10 an owner o( Required Inspections
pro~J1y who builds or improves thereon, and who docs such work himsel( or through his
own employees. provided thal such improvemenlS an: nol intended orofTered (or sale. 1(,
however. the building or Improvement Is sold wllbin one year o( completion. the owner-
builder will have !he burden o( proving thai he did 00' build or improve (or purposeof
sale.).
D J, as owner o( !he pro~J1y, am exclusively conlraCling wilb licemcd contraelors to
COnslroC\!be project (Sec. 7044. Busioess and Pro(essions Code:) The Conlrae~r's Li·
cense Law docs no' apply 10 an owner o( property who builds or improves tbcrcon. and ,
who contra~ (or such projeel.s with a conlraCton') licensed punuanl ~ the Contractor's
License Law.
D I am eaempt under Sec. , B 8< P C (or Ibis reason
Owner -::-====-======:-:-:==-=Date _
WORKER'S COMPENSATION DECLARATION
1 hereby affinn under penally of perjury one o( the (ollowing declarations:
D I h."" and will maintain a Ccrtiflcateo(Consenl10 sel(·insure (or Wor1ccr's Com~
sation. as provided (or by Sec:tion 3700 ~ the Labor Code. (or lhe ~rformancc o(!be
wo<1c (or which this permil is issued.
D I have and will maintain Worker's Corn~ation Insurance. as required by Section
3700 o( the Labor Code, (or the ~rformancc o( the work (or wbich this ~rmil is Issued.
My WOr1ccr'J c:~~on In.u~cc carrier,and Policy nu~ are:
Carrier. '-/~_ f>t~o,: 6111#
C ACAlC OF EXEMI'TION FROM WORKERS'
COMPENSATION INSURANCE
(This section necd not be completed i(!be permit is for one hundred dnll ... (SIOO)
or Icss.)
I certify mQI in the performance of the work. (or which this permit is issued. I shall not
c!I1ploy an)· person in any manner so as lO become subjccl to the Worlcers' CompensationLaws o(Cali(ornia. Dale _
Apptican' _
NanCE TO APPUCANT: 1(. a(lCr making this Cenificale o( Eaemplion. you should
become subject 10 the Work.er's Compensation provisions or lhc Labor Code. you must
rorthwilb comply with such provisions or this pc:~il shaH be: deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby afli... thai the", is , eonstrue.inn lending a~ncy lor the ~rformanco o(
Ibe wo<1c (or which !hi. ~rmitl. issued (Sec. 3097, Civ. C.)
Lender's Name -------------Lcnder'sAddrcss _
Jcertify lhal Jhave read this application and SLaIC lhal the above infonnauon is
correcL I ag.rct 10 comply with all city and county ordinanteS and SLalC laws ~launlLO
building consuuetion. and he~by authOri7.e n:prcscnlaUVCS of lhis cily La enlCr upon lhc
.hove-mentioned p~ny (or inspection purposes.
(We) agree to save, indemnify and keep bonnl ... !he C1,y o( Cupertino againsl
liabilities, Judgments, eo.LS and ea~nscs which may io any way accrue againsl said Oly
in consequence of !he gr2nting o( Ibis ~iL
APPLICA UNDER NOS 0 COMPLY WITH ALL NON-POINT Issued by:
Re-roofs
DalC
HAZARDOUS MATERIALS DfSCLOSURE Type of Roof
Will the applicanl or future building OCCUpantS1Orc or baJtdle hv.ardou. malCrial
as defined by the Cupertino Municipal Code. Chapler 9.12, and the Health and Safely
Colic, Section 25532(a)1 J. All roofs shall be inspected prior to any roofing material being installed.DYes III No
If a roof is installed without first obtaining an inspection, I agree to removeWill the applicanl or [ulure building occupanl USC equipmenl or lIcviccs which
emit ha;r.ardous 3ir contaminanlS as defined by (hc Bay Area Air Qualily Manz.gemcnl all new materials for inspection.
District? /
DYes u;rNo
I have read the bv.ardou. materials requirements under Chapler 6.95 o( the Cali(or
nia Hcolth '" SafelyCodc, Sections 25505, 25533 and 25534. IundCl>land thali(the building
docs nm cu have a tcnant., lhal it is m .. notify the occupant of the
rcquiremen ch muSI be me' 10 i ertiJicale o( Occupancy, Signature of Applicant Date
All roof coverings to be Class "ft." or betterDOle
n lor
SOUR E U