07100040 CITY OF CUPERTINO ' < '
BUILDING DIYISION PERMIT �������� �����������
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BUILDING ADDRESS: PERMIT NQ
10495 N DE ANZA BLVD TAISEI C'ONSTRUCTION CORP 07100040 .
�ER'S NAME: PERMIT ISSUE DATE
SAND HILL/1200 SAN MATEO AVE 2180 BEF�ING DR 10 22 2007
PHONE: T r' SANITqRY NO. CONTROL NO.
(714) 88E�-1530
ARCHITECT/ENGINEER: BUfLDING PERMITINFO
BLDG ELECT PLUMB MECH
�� � � 0
i o p LICENSED CONTRACTOR'S DECLARATION
� V� I hcrcby affirtn that I arn licenscd undcr provisions of Chap�cr 9(commcncing Job Description
; Z, � with Sccdon 7000) of Division 3 of thc Busincss and Profcssions Code and my liccnsc is NEW �M� � S SAN I TARY REQU I REMENT S. P LANN AP PRV
'� y in full force and eftec�
��z LicenscClaSS �ic.a LIMITED TO HANDICAPPED ACCES IMPRV� LIGHTS &
: �, � Datc Contracwr
ARCHITECI'SDECLARATION BOLLARD .
i a a 1 undcrstand my plans shall bc used as puhlic rccords
�yV
� 0 y Licenscd Pn�fessional
� y � OWNER-BUILDER DECLARATION
j '>' 1 hcrcby al6rm Ihat 1 am cxcmpt Crom ihc Contractor's Liccnsc Law for Uic
p o following rcuon. (Secuan 7031.5, Busincss and Profc.uions Calc: Any eity ar county
�,°, �i which requires a pertnit to conswct, alur, improvc, dcmolish, or icpair any strucmre
� Z y prior ni ils issuancc, also requires ihc applicanl Cor such permit to filc a signcd s�atcment
�= a�hat he is licensed pursuant to me pmvisions o( me Convactur's [,icense Caw (Chapicr 9 S q. Ft. Floor Area Valuation
� h$ (commencing wiih Scction 7U00) of Division 3 of Ihc Busincss and Profcssions Cadc) or $ 3 � � �
��... that he is ezempt themfrom and t6e buis [or the allegcd exemption. Any violaGon o[
Section 703I.5 by any appliCant tor a pertnit subjects ihe applicant to a civil penalty o( Number Oeeupaney Type
� o� mo� m� r� h��aRa aau� cssoo>. 3 2 6 3 311( � ��
❑ I, as owner of ttie propercy, or my cmployces with waga u their solc compensadon,
will do the work, and �he stcuctur is not intended or offued for sale (Sec. 7044, Business Re uired Ins CCt10IlS
and Professions Code: The Conuactor's License Law docs nat apply w an ownu of Q p
propeny who builds or improves �hercon, and who daes such worlc himself or Uuough his
own employccs, providcd that such improvemenls ate not intended ar oRered for sala I[,
however, the building or improvement is sold within one year of completion, the ownu-
builder ill have the 6urden o[ proving that hc did not build ar improvc Cor puryose o(
sale.
, as owner of the property, am exclusively conuacring wi�h licensed rnnuactors w
nstruct �he project (Sec. 7044. Businas and Rofasions Code:) The Contracmr's Li-
ccnse Caw docs not apply to an owner af propeny who builds or impmva �hereon, and .
who contrac�s for such projects wi�h a conuactar(s) licensed pursuant to tltc Contractor's
License C.aw.
' I am eacempt un � S�c. , B& P C for this rcu
.vner Date __ 1 � \
W RKER'S CO 'ENSATTON DECLARATION
I hercby �rm under penalty o[ perjury onc of the following declarations:
❑ I hsae and will mainiain a CeniGcate of Consent to self-insure for Workc�s Compen-
sarion, as providcd for by Section 3700 of the Labor Code, far the perfarmaMC oC Ux
wark for which �his pertnit is istued.
❑ I havc and will maintain Workcr's Compensation Insurantt, as rcquired by Scction
3700 oC ihc Labor Codc, for thc pertormancc o( ihe worlc for which this permit is issued.
My Warker s Compensation Insurance cacricr and Policy number are:
Cartier. Policy No.:
CERTIF[CATE OF EXEMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE
(This sectian nccd noe bc campleted if the pertnit is for onc hundred dallazs (E 111Q)
or IessJ •
I ccnify that in thc performancc of thc work for which ihis pertnit is issucd, 1 shall not
employ any pccson in any manncr so as w bcco 3 bj Ae Workcrs' Com sation
Laws of Cali(ornia. Datc —
Applicant
NOTICE TO APPLICAM: If, af�cr making Wis CcrtiC • c of Ezcm ', yau shoulJ
bccome subjcct to tAc Workcr's Compcnsation provisions af ihc Latwr Codc, you mus�
� O fonhwi�h comply with such provisions or this pecmi� shall be dcemed revoked.
z ""' CONSTRUCTION LENDING AGENCY
[— .�—� I herehy affirtn that there is a conswctinn Icnding agency Cor thc performance o(
�Y. � thc work fur which this pecmit is issucd (Scc. 3097, Civ. C.)
a Q Lendcrs Namc . •
� z L.cnder's Address
V � I certify Ihat f havc rcad lhis application and stalc that Ihc a6ovc infortnauon is
w � cortect. I agrce to wmply with all ciry and county oniinanms and su�e laws celating �o
0 U building conswct�on, and hercby authori�e rcpresentatives of ihis city to emer upon thc
� W ahovc-mcn�ioncd properly (or inspcc�on purposes. �
(Wc) agrce to save, indcmni(y and keep harmless ihc City of Cupertino against
�� liabilitia, judgmcnts, cas�t and expenses which may in any way accruc againsl said City
V,'�' in consequcncc of thc granting of this permi� Date jv �Z--
� APPLICANT UNDERS"fANDS AND WILJC�OMPLY WITH ALL NON-POINT Issued by: 2 �
SOURCE REGULATIONS. 1
� � . � �` Ly�� Re-roofs �'
SignawrcolApplicandContractor ' Datc '
HAZARDOUS MATERIALS D[SCLOSURE Type of Ro of
Wil1 Ihc applicant or Cuturc building occupant starc o� handle harardous matcrial
dcfincd by lhc Cupertino Municip Codc. Chaptcr 9.12, and �he Hcalth and Safcty
�� Scction 25532<a)? All roofs sl►atl be inspected prior to any roofing material being installed.
❑ vcs o
wll thc applicant or futurc building accupant usc cyuipmcnl or ticviccs which If a roof is installed without first obtaining an inspection, I agree to remove -
cmi� ha•rardous air contaminan�s as dcfincd by �he Bay Arca Air Quality Managcmcm all new ma:erials for inspec*ion.
District?
❑ Ycs � '
1 havc read U�e haiarCous matcrials rcquircmen� undcr Chap�cr 6.95 o(ihc Califor-
nia Hcal�h & SafctyCodc, Sections 25505.25533 and 25534. I uncicrstv�d that iC�hc building
docs not curtcnlly havc a tcnan4 a[ i' my responsibilily to noufy lhc acupant o( Ihc
rcyuircmcn�s which must hc m p' issuanu of a Cenifica�c of Occu ��r_ Signature c f Applicant Date
1 `�� ZY1 �� All roof coverings to be Ciass "B" or better
Owncr or authori agcdt Datc