09040122BUILDING DIVISION PERMIT
BUILDING ADDRESS:
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10500 N DE
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ARCHITECT/ENGINEER:
LICENSED CON -1 KAL IUK3 ur.Ltruuu IV"
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
in full force and effect
License Clams y Contractor '[2 ldnFAJ
Date ��
RCHITECTS DECLARATIOIT
I understand my plans shall be used as public records
Licensed Pmfcssional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License 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 Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements arc 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 contractors) licensed pursuant to the Contractor's
License Law.
1 am exempt under Sec. B & P C for this mason
miner Date
WORKER'S COMPENSATION DECLARATION
PERMIT NO.
LC 09040122
PERMIT ISSUE DATE
tAjdfA*YV0? 0 9 9 CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
0
Job Description
COM'L TI PRTN&CEILNG DEMO& NEW RECONF WINO CHNG
IN
EXTER (1384SQ)
I hereby affirm under penalty of perjury one of the following declarations:
] I have and will maintain a certincate of Conscnt to self-insum for worker's compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
] 1 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 Worker's Compensation Insurance carrier and Policy numh
't c
Cartier.[ Policy No.:
CF-RTTFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cutis section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 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 them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and stake that the above information is
correcL 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize 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 scenic against said City
in consequence of the granting of this permit.
APPLICAgIUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR GULA ONS,
ta. re o Acam/Co for amHAZARDOUS MATERIALS DISCLOSURE
the applicant or future building occupant store or handle hazardous material
by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
tiction 25532(a)?
0Yes ❑No
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
District?
0Yes ONO
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & SafelyCode. Sections 25505, 25533 and 25534.1 undersand that if the building
does not curretyly have a tenant, that it is my responsibility m notify the occupant of the
mouiremantsAGhich must bpmet prior to issuance of a Certificate of oc?tpancy
3q. Ft. Floor
3162201" . FLR1
Issued b)
Re -roofs
Type of Roof
Valuation
Required Inspections
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 rTaterials for inspection.
Signature; of Applicant
All roof coverings to be Class ". or better
Date
CITY OF CUPER"I'll\'O BUILDING PE -MMI I'
BDD.DING ADDRESS: 10500 N DE AN%A BLVD PLR I
C0A'I'RACI'0w DEVCON
PratMrr.'O: 09040122
CONSTRUCTION INC
owscR's �.(>le: APPLE INC
690 GIBRALTAR DR
I)XIT ISSIieu:05/14/2009
owxr:R's Pnosr: 4088629799
MILPITAS. CA 95035
PHONE NO: (108)9.2-8200
❑ LICF:NSI{D C(')A'I'I(ACI'0It'5 DE(A ARATION
r r r
B til LDING FERMI' INFO: HIMG. EAXCI11I.I1Mn
License Glass Lic. a
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?I F.ClI RF.SIDF:CTIA. COM.N ERCIAL
Contractor Dae
I hereby affirm that I run licenced under the provision. of Chapter 9
•1011 DFS(R IPHON: CONI'I.'I'I PR I'N&CI:1LNG DEMO& NEW R17CONI: WINO
(cam nwncin2 with Section 7000) of Division 3 of the Rosiness & Proressinn,
CIING IN
IxI'I:R (1384SQ)
Cade and that wr limn>e is full lot cc and el feet. 1.
I hereO'affirm nndcr prnahy of prrjun' one uhhe fullos%ing loodeclination,:
I haws :cod will maintain a eenil irate ul amsenl uh sell' -insult tort Worker's
Compensation, as provided lar by Section 3700 of the Labor Code, for the
Sq. PI Floor,xm:c
Valuation: 5125000
perfonmmee of the work for scllich [his permit is issued.
I lime and evil[ maintain Worker's Compensation Insurance, as provided Ivor by
Section 3700 ofthe labor Code, (or the performance of the Bork lou which this
permit is issued.
AI:S Number: 31622017.I7I.R I
OccupancyTpe:
A I.1'IACA\T CERTIFICATION
I certify that l have read this application and state that the above ininulation is
PERI\'l l"I'E\PIIt1:SIF\\'O12K IS NO"I'S"1'A It"1'ED
correct. l agree to comply with all ciy and comity ordinances and state lags relatin_e
WITHIN I80 DAPS OI'1'IiliD'1l"1'I$$UAI\Chi OR
building construction, .and hereby authorize representatives of this city to enter
upon the above mentioned property lire inspection purposes. (We) agree ser save
180 DAPS FROIN1 LAST CA LL ED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities. judgments.
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by: Date:
with all non -point source regulations per the Cupertino Municipal Code. Section
9.18.
R E-Id00 FS:
Signmtre Dae
All root'sshall be inspected prior In an)• roofing material being installed. ICa roof is
installed without first obtaining an inspection. I a__ree to remove all tie%%materials tie
inspection.
❑ O\\;\lilt-BUILDF:It DECI.AHATIO\'
Signature of Applicant: Dale:
1 hereby affirm thatI am exonpl from Iter Contractor'sContractor'sLicensens% [.:it, for our of
Ihr following, nth reasons:
ALL ROOF COVERI:\GSTO BE CLASS "All OR IiiC TF:It
1. as owner of the properly. or tip' employees with wages as their sole compensation.
will do the work, and die structure is not intended or offered far sale (Sec.7044,
Business & Professions Code)
1. as owner of rhe property•, am exclusively contracting with licensed contractors to
I IAZA IMODS NIA'I ER IA LS DISCLOSOR I.
construct the project (Sec.7044, Business & Professions Code).
I ha, read the hazardous materials requirement under Chapter 4.95 of the
California Iledlh & S:fet%Code. Sections'_55115,?5533, and 25534. 1 Bill
I hereby arftrm under penally of perjury' one of the fo[Imvilia three
maintain conk pli:mce with Ihr Cupertino Municipal Code. Chapter 9.12 and the
decl:u'ations:
Ilealih & Sal'ep• Code. Section 25532(:) should I store or handle hazarduu,
I have and will maintain a Certificate of Consent to sell' insure for Worker's
material. Additiunaliv. should I use equipment ser de, ice, which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay A rea Air Qualily .\ lanaactornl Di,t, icl I
pertllrmance of the work for %)rich this permit Is Issued.
\Pill maintain compliance with the Cupertino Municipal Code. Chapter 9.12 :sed
I'have and will maintain Worker's Compensation Insurance, as provided for by
the Health S Safely Code, Sections 255115, 25533, and 25534.
Section 3700 of the Labor Code, for the perlimnance of the work Ibr which this
per»iI i5 issued.
On'ner or authorized agon: Daie:
I cerify that in the performance of Elie e'ork liter e'hich this permit is issued, I shall
not crib loy an)' person nn any manner so its In become Subject to the Worker's
Compensation l'ab's of Cahlbona, ll, Aller making this certllicuo: ofewininion. I
CONS'I'It(ICr1ON LESDI\•G AG1 SCY
become subject to the Worker's Compensation provisions of rhe labor Code, I must
I herchv infirm that there is a construction lending agency lin the perlbnr,utec of
forthwith comply with such provisions or this pernil shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Cir C.)
Lender's :Caine
AI'I'LICA:NT CERTIFICATION
Lender's Address
I ceryl lv (hill I have read this app l l cation and stall' that Elie aha\'e In lO no in 1011 Is
correct. I agree to comply with all city and county ordinances and state Imes relating
to building construction, and hereby authorize representatives of this city to enter
upon (he above mentioned property for inspection purposes. (We) agree to save
indenmitV and keep harmless the City ol'Cuper[ino against liabilities, judgments.
,UtCl11'I'I[CI"S DECLARATION
costs, and expenses which mayaccrue against said City in consequence of the
I understand 111\' plans stroll be used its public records.granting
of this permit. Additionally, Elle applicant undersuulds and will comply
with all non -point source regulations per Elie Cupertino Municipal Code, Section
Licensed Professional
9.18.
Signature Dae