09070037BUILDING DIVISION PERMIT
BUILDING ADDR
20400 STEVENS CRE
0 W NIB'S DIME:
ARCHITHCf[ENGINEER:
u o p LICENSED CONTRACTOR'S DECLARATION
U p I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z w with Section 7000) of DivJ'�tion 3 of the Business and rg(es;�a�CWd4, and my license is
< o. in full force and effect d"�I! SVC `%
:n) z License I s a J Lic. N
F itsDale Contractor
,a ARCHITECTS DEC RAT! N
oC < I understand my plans shall kused as public records
DyU
y Licensed Professional
a y OWNER -BUILDER DECLARATION
< I hereby affirm that I am exempt [rum the Contractor's License Law for the
O O following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to ennswct, alter, improve, demolish, or repair any structure
y Z } prior to its issuance, also requires the applicant for such permit to file a signed statement
i ='c that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
y. t— (commencing with Section 7000) o[Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars (5500).
❑ 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 sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
properly who builds orimproves thereon, and who doessuch work himself or through his
awn 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 pmject (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 pmjects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby atTrtn under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insuc 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 Labor Code, for the performance of the work for which this permit is issued.
My Work er';Corppe`s . Insurancgcarrier and Policy nju�m9lb�are• % al
Cartier. \I-3ar it `R1't Policy No.: Fff� vv ~ —"
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or leu)
I certify that in the performance of the work for which this permit is issued. I shall 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 Worker's Compensation provisions of the labor Code, you must
rJ Z forthwith comply with such provisions or this permit shall be deemed revoked.
.�
O CONSTRUCTION LENDING AGENCY
I hereby affirm that where is a construction lending agency for the performance of
R�+ the work for which this permit is issued (Sec. 3097, Civ. C.)
0 Lender's Name
Z Lender's Address
U O 1 certify that 1 have read this application and state that the above information is
LT. ""' correct I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction, and hereby authorize representatives of this city to enter upon the
H aabove-mendoned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments• costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permt�
APPLL92 U UNDERSTANDSIAND Wll)I, COMPLY WITH ALL NON -POINT
Sig pplicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Codc, Chapter Al2, and the Health and Safety
Code, Section 75532(a)?
❑Yes ,*a
Will the applicant or future buildingoccupant use yuipment or devices which
emit hazardous air contaminants as defined by the Bay A a Air Quality Management
District?
❑ Yes gNu
1 have read the hazardous marcrials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that if the building
dps-rttt currently have a tFnant thd\t is my responsibility to notify the occupant of the
M
lao,
4082468600
Job Description
COM'L TI NEW PARTIONS, DOORS, FINISHS,
NON-STRUCTRL INCLDING E/M (SPLIT SYS) (2492SQ)
q. Ft. Floor Area
147
36901028.5850
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date %—Z /
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class'n" or better
PERMIT NO.
PERMIT ISSUE DATE
S A
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT PLUMB
Job Description
COM'L TI NEW PARTIONS, DOORS, FINISHS,
NON-STRUCTRL INCLDING E/M (SPLIT SYS) (2492SQ)
q. Ft. Floor Area
147
36901028.5850
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date %—Z /
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class'n" or better