07050056 CIT�' OF CUPERTINO ° ' °
BUILDING DIVISION PERNIIT
+G�1��A�T�'1� ��t�+t?I��iTI�N' ' ;
_ . . :., ,
PERMIT NO.
BUIL niN� ���ES� DE ANZA BLVD AS SOC IA7'ED CONTRACTORS CORP 0 7 0 5 0 0 5 6 .
PERMIT ISSUE DATE
OWNER'S NAME:
SANDHILL PROPERTIES 1624 DEI,L AVE, STE D 10/04/2007
SANITARY NO. CONTROL NO.
,"E: (408) 37E�-4000
BUILDING PERMIT INFO
ARCHiTECC/ENGINEER: BLDG ELECT PLUMB MECH
� � 0 �
� p � LICENSED CONTRACTOR'S DECLARATION JOb DOSCiIptlOil
;�� ! tkrcby afGrm that I am liccnxd umlcr pravisions of Chaptcr 9(commcncing
: z� with Scction 7000) of Division 3 of thc Business and Profcssiuns Codc and my liccnsc is T. I.— REI �OCATE 2 DOOR S, NON S TRUCTUR.AL � N�
?�y infuOCorccandcf[ect LIGHTING� ELECTRICAL. OFFICE SP A C E— A S S O C I A T E D
� v� z Licensc Gass L�. �
: F o p Co�uactor C�NTRAC�.'ORS # 2 0 9 9 7 RENEWED BL 5/ 8/ 7.
� ARCHITECI'S DECLARATION
i a Q ! undcrsWnd my plans shall bc uscd as public rccords
)yU
' w y Liccnscd Pcu(cssional
; � < OWNER-BU(LDER DECLARATION
� t� I hcrchy at7rm �ha� 1 am cxcmpt Crom ihc Contraaors Liccnsc Law far thc
p o Collowing rcason.. (SccGan 71131.5, Busincss and Profcssions Calc: Any city or couniy
�,°, � which rcquires a permit to cnnswc4 alicr, improvc, dcmolish, or repair any structurc
rior w iLS issuancc, alsu rcquircs thc applicant for such permit to Glc a signcd su�cmcnt
_ Z r r � q. Ft. Floor Area Va uation
a that hc is liccnscd pursuan� to thc provisions o( ihc Convactar's Li�xnsc Law (Chapicr 9 $110 0
Y�� (commcncing with Scction 7000) of Division 3 of tlic Busincss and Profcssions Codc) or
i 3� �hat he is exempt thetefrom and ihe bazis (or the allegcd ezempUoa Any violadon o(
Secdon 7031.5 by arry appiicant for a pemtit subjccu �he applicant to a civil pcnalty of 3 2 6 3 4 0 7:��� Number Oecupaney Type
not morc than fivc hundred dollars (5500).
� I, as owncr o[ ttie property. or my empioyces with waga as the'v solc compensation,
willdothcwork,andiheswctureisnotintendcdorof[erodforsalc(Sec. Required Inspections
and ProCessions Code: The Conuactors License Law docs not apply m an owner of
propeny who builds or improves thereon, and who daes such work himself or Uuough his
own emplayces, providcd that such improvements are not intended or otiered for sale. I[.
however, the building or improvement is sold within one year of complction, the owner-
builder will have the burden of pmving that he did nat 6uild or improvc for purpox of
salcJ.
p I, as owner of ihe propeny, am acclusively conlracting wiW licensed contractars W
wnswct U�e project (Sec. 7044. Business and Professions CodeJ The Convactnr's Li-
ccnu Law dacs no� apply w an owner of propeny who 6uilds or improves ihe�eon, and ,
who convacts for such pmjec�s wi�h a coniraaor(s) licensed pursuant to �he Convactors
License Law.
❑ I am exempt under Sec. , B& P C for this rcason
Owner Date _... __
WORKER'S COMPENSAI'fON DECLARAT(ON
I hercby affirm under penalty o[ perjury one o[ the (ollawing dalarations:
❑ I hsve and will maintain a CertiGcatc of Consent to self-insure !or Workc{s Compen-
sation, as provided for by Section 3700 af the Labor Cade. for �he performancc af the
woric for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insunnce, az reyuired by Seceion ,
3700 0[ the Labor Code, for �he performance of �he work for wdich �Ais permit is issued
My Wodcec' ompensaoan I�sunnce carticr and Polity numbcr are:
Carrier Policy No.:
��
CER FICA Q P'I'ION FROM WORKERS'
COM NSATION INSURANCE
(This scctioa necd nol bc complctcd if the permit is Cor onc hundred dallacs (5100) ,
or Icss.)
l cenify thxt in thc performance of ihe work for which Wis permit is issued, 1 shall not
employ any person in any manner so az ta become subject �o �he Workers' Campensation
Laws o( Califomia. Date
Applicant
IYOTICE TO APPLICAM: lf, aftcr making this CcrtiGcatc of Ezcmption, you shaulJ
bccome subjcct to thc Workcr's Compcnsation provisions of ihc Labor Cadc. yau muu
�,`� (oMwitl� comply with such provisions or this pccmit shall bc dccmcd awokcd.
Z O CONSTRUCTION LENDING AGENCY
[.~-� � • I hcreby amrm Ihat there is a constructinn lcnding agcnry far thc performance uf
p(, � ihc work Cor which this permit is iuucd (Scc. 3097, Civ. C.) ,
W A Lendcr's Namc
a z L.ender's Addrcss
1 ccrtify ihat f havc rcad this appliwtion and sutc iha� thc abovc intortnatiun is
� O corrca. I agree �o comply with all city and county ordinances and sutc laws rela�ing to
� U building conswction, and hcrcby authome rcprescntativcs of this city to cntcr u{xin �hc
�� atwvc-mcntioncd property for inspccdoa purFwses.
a (We) agree to save, indcmni(y and kecp harmleu �he City of Cupcnino against
�� liabiliuu, judgmcnls, costs and expcnscs which may in any way accruc against said Cay
U z i^ consequence of the granting of ihis permit.
� APPLICAN'C UNDERSTANDS AND WIL[. COMPLY W1TH ALL NON-POIN'f Issued by: ate ���
SOURCE REGH�A'�10NS. .
b - D� Re-roofs
Signature of Applicant/Conuacto Da � T of R�of -
HAZARDO S MATER[ALS SCLOSURE YP
�II ihc applicant or fuwrc building acupant storc or handlc ha•rardous maicria!
u dc6ncd by the Cupenino Municipal Codc. Chaptcr 9.12, and thc Hcal�h and Safety
Cwk.Sccdon25532(a)? � All roofs :�hall be inspected prior to any roofing material being installed.
❑ Ycs .
Will ihc applicant or fuwrc building occupant usc cyuipmcnt or ckvices which
If a roof i;> installed without first obtaining an inspection, agree to remove
cmit harardous air con�aminan�s as ekfincd by the Bay Area Air Quali�Y Managcmcn� all new m aterials for inspec �1011.
Disuic�?
❑ Ycs No
1 havc reaci the ha�arCous materials rcquiremcn�s unckr Chap�cr 6.95 af ihc Calitor-
nia Hcalth & Safcry Codc, Secuons 25505.25533 and 25534. [ undcrstand thaz iC thc 6uildin$
docs not curren�ly havc a tcnan4 ihat il 'u my responsibility ta notiCy ttrc occupant af �hc
c
rcyuirements which must be met prior �o issuance oCa Cenificaic of Occupancy. S1gTldLllTe Of AF)(�I1C2Rt 11 Date
° — d All roof coverings to be Class "B or better
Owncr or authorized agcm ' ���