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CITY OF CUPERTINO
DIVISION PERMIT
G(T I�tRTI�
BUILDING
BUILDING ADDRESS:
PERMIT NO.
10201 TORRE AVE
VKK SIG:VMAKERS INC
n9n7n128
nWNER'S NAME:
PERMIT ISSUE DATE
PHO
A CONTROL NO.
(650)363-0931
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
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
in full force and effect. 7 Z Z
INSTL (2) NON- I LLUMNTD MONUMENT SIGNS
License CI s Lie. k
Date Contractor
(%$
ARCHITECTS DECLARX1110A
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demoiish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
6 O O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (s5W).
36941003 .00
❑ I, as owner of the property. or my employees with wages as thew sole compensation,
Required Inspections
e: q P
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions CodeThe 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.).
❑ 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 Contractor's
License Law.
❑ 1 am exempt under Sec B & P C for this reason
`rvner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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 f ich this permit is issued.
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 Worker's Compeansadon Insurancecarrier and Policy number am::
�
Cartier. �,—A, f� l N S • uy,)\D Policy No.:4• 1ern At !
CERTIFICATE OF EXEMPTION FROM O CE tS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
or less.)
1 cenifv 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
forthwith comply with such provisions or this permit shall be deemed revoked.
)
" CONSTRUCTION LENDING AGENCY
+ I hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
cormcL I agree to comply with all city and county ordinances and state laws relating to
" building construction, and hereby authorial representatives 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, costs and expenses which may in any way accrue against said City
r in consequence of the grantin is permit,
APPLICANT UNDER AND W PLY WITH ALL N N-Z54-
Issued b y Date
SOUR EGU
Re-roofs—�
Type of Roof
plittarrUCo forDa
HAz DOUS MATERIALS DISCLOSURE
7asfin:edioby
ll the applicant or future building occupantstore or handle h ous material
the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
^,de, Section 25532(a)?All
UNo
roofs ;,hall be inspected prior to any roofing material being installed.
❑Yes
If a roof i; installed without first obtaining an inspection, I agree to remove
Will the applicant or [inure building occupant use equipment or devices which
emit hazardous air contaminantsas d med by the Bay Area Air Quality Management
contaminants;
all new materials for inspection.
District?
❑Yes
1 have read the haaardous rials requirements under ptcr 6.95 of the Califor-
nia Hcalth & Safety Code, 0 505, 25533 and 25 dcrstarrd that if the building
does not 0 h a n4 that it is my i ' y to notify the occupant of the
re met prior o iss Certificate of Occup
Signature of Applicant Date
All roof coverings to be Class 'rj" or better
ow or tharizcdagcnt D