09060107 CITY OF CUPERTINO
BUILDING DIVISION PERMIT + �1TR�� CTR ItMAI� . '
BUILDING ADDRESS: PERMIT NO.
20530 TOWN CENTE-R_ I-NRF. nF.
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
ABUILDING PERMIT INFO
RCH1TECf/ENGINEER:
BLDG ELECT PLUMB MECH
u o p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
� y in(ullCorceand eff ? _ ONE SET OF PAN—CHANNL LTRS ATTCHD TO
s 12 Z License Class Lam• ■
Date contractor WALL(EN7'RNC)&
ARCHI ECPS DECLARA O
�d< 1 understand my plans shall be used as public records ONE NON- ILLUMINATED LOGO
DWU
.01 WIn Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K which requites 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
x that he is licensed pursuant to the provisions of the Contractor's Irm rise Law(Chapter 9 Sq.Ft.Floor Area Valuation
nt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 82500
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(S500).
0 1,as owner of the property,or my employees with wages as their sole compensation, 36955082 - 01
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law docs not apply to an owner of 9 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 will have the burden of proving that he did not build or improve for purpose of
sale.).
0 1,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 thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
0 I am exempt under Sec. B&P C for this mason
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.
0 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 Workers Compensation Insurance carrier and Policy number are:
Carrier Policy No.:
CERTIFICATE OF EXEMP'T'ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far 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 anym so cgmc subject to the Workers'Compensation
Taws of California.Date "�
Applicant_Is Mit
NOTICE TO APPLI ANT:If,atter making this Certificate 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.
Z'"d CONSTRUCTION LENDING AGENCY
(�►��. I hereby affirm that there is a construction lending agency for the performance of
ai> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lendces Name
Lenders Address
U 0 1 certify that I have read this application and state that the above information is
LL"0 correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize represontatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs,and expenses which may in any way accrue against said City
U Z in consequence of the g ng of this permit. Date �� y
r"r APPLICANT DER ANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOUR R G S.
Re-roofs
Signal pplicant/Conusctor Dam Type of]Roof
HAZARDOUS MATERIALS DISCLOSURE yP
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
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes J�rNo
If a roof i 3 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?
0 Yes Nu
1 have mad 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 curren have a nano that it is my responsibility to notify the occupant of the
requirements w h mus be met prior to issuance of a Certificate oftOcatp Signature of Applicant Date
All roof coverings to be Class']."or better
Owner o onzcd agent Datc