07100046CITY OF CUPERI'liNu
BUILDING DIVISION
BUILDT8n FSS,
N WOLFE RD
OWNERSNAME;
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PERMIT NO.
07100046
PERM17 ISSUE DATE
1OZ04/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing Job Description
ith Socdon7000) o(Division 3 of the BusiDVProfessions Cc&, and my license is DEMOLITION; WALLS @SPACE 8, 9, 10 COM'L
, lull force and
teens. Class
CENTER
late 44 ARCHITECTS Contractor DECLARATION
I understand my plans shall be used as public records
Icensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from The Contractor's License Law for the
31lowing reason. (Section 7031.5, Business and Professions Code: Any city at county
vhich requires a permit to construct, alter, improve, demolish, or repair any structure
,rior to its issuance, also requires the applicant for such permit to rile a signed stateroom
bat 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
hat he is exempt therefrom and the basis for the alleged exemption. Any violation of
;action 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
tot more than five hundred dollars ($500),
as owner of the property, or my employees with wages as their sole compensation,
?viR do the work, and the structure is not intended or offend 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 work himself or through his
awn employees, provided that such improvements an 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 or
sale.).
r7l 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) Tim Contractor's Li -
cerise 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.
0 1 am exempt under Sec. B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decimations:
0 1 have and will maintain aCertificate 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 for which this permit is issued. ,
Q 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 Worker's Corripensalmn Insu Cc carrier and Policy n
— 6. dl umber am:
"'VT.
0-
Carrier: Policy No.:
CE CATE OF EXEMPTION MOM WORKERS'
COMPENSATION 114SURANCE
(This 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, 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
beconuk 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
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws misting 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 accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG LATE NS.
Signal ffi ofAriplicant/Contractor
T HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.17- and the Health and Safety
Code, Section 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 e5 IN.
I have read the hazardous materials requirements under Chapter 6.95 of die Califor-
nia Health &Safety Code, Sections 25505,25533 and 25534. 1 understand thatif the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be meLlmor to issuance of a Certificate of Occupancy.
7
M
Issued by:
Re -roofs
Type of Roof
Area
Required Inspections
Date
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 "13 " or better