09060040CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT
BUILDING ADDRESS:
PERMIT NO.
1
OWNER'S NAME:
PPT-HCONTROL
PERMIT ISSUE DATE
PHO
N0.
408)942-8200
ARCH17ECTIENGINEElt:
BURRING PERMrrwo
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECL.ARA7 ON
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Businessand Professions Code, and my license is
in full force and effect f7
COMM'L TI (17,681SQ)1ST FLR TO LOBBIES COMMON
o te 6�—�CCoontrract�or vr��n z--7 �'P.�-�r"
.&
CORRIDORS, NO OTHR INTER OR EXTER WORK, NO CHNG
ARCHr1ECrS DECLARATION
I understand my plans shall be used as public records
IN
USE, EXITING OR OCCUPNCY
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's Ucense Law for the
following mason. (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
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70(l0) of Division 3 of the B usinecs and Professions Code) or
2 5 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70313 by arty applicant for a permit subjects the applicant to a dvil penalty or
not more than five hundred dollars (S300).
31622017 F LR 1 .
❑ L as owner of the property, a my employees with wages as their sod eompemudon
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 70", Business
and Professions Code: The Contractors 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.).
❑ L as owner of the property, an exclusively contracting with licensed contractors to
construct the project (See 7044. Business and Professions Code:) The Contractors U-
eense 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.
❑ I am exempt under Sec , B & P C fro this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby AM= under penalty of perjury one of the following declarations-
❑ 1 have and will maintain a Certificate of Consent to self-insum for Workers Compm-
scion, 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 Workers Compensation Insurance, as required by Section
3700 of the fsbor Code, for the performance of the work for which this permit is issued
'
My Worker's, Compensation r�� , carrier and Policy number am:
Carrler���Sd�V1rYF fix/ Porky No :
CERTIFICATE OF EXEMPTION FROM WO CERS'
COMPENSATION INSURANCE
0-his section need not be completed if the permit is for One hundred dollars ($100)
or lets)
I certify that in the performance of the work rot which this permit is issued, I shell not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Lobar Code, you must
forthwith comply with such provisions of this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 hereby affirm dw there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C)
'
Lenders Name
,
Lenders Address
1 certify that I her read this application and state that the above information Is
correct I agree to comply with all city and county ordinances and stale Laws relating m
building constructlon, and hemby authorise represe tLady s of this city to enter upon the
above -mentioned property for inspection Purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cops and expenses which may In any way accrue against said City
in consequerrcce oC granting of this permit
APPLICANT DERSI'ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date /
S R RdIULAMYA.
Re -roofs
g
ou A DlscLosuRE
Type of Roof
Wil applicant or future boil ng oav" atom a handle hanrdotu material
as d� y the Cupertino Municipal Code, Chapter 9.I2. and the Health and Safety
C .0532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fu building occupant tuc equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes No
I have read the hazardals mWimments under Chapter6.95 of the Califor-
nia Health & Safety Code, Sections 255M. 23533 and 25534. I understand that if the building
does not currenU vs- a t,n L that it is my responsibility to notify the occupant of the
mqn c h mtut be reel ' rto issuance of a Ccrdr—of MSignature
of Applicant Date
All roof coverings to be Class 'A" or better
o e nrz eat ate