07090104 CITI' OF CUPERTINO ` ' `
BUiLDING DIV1S10N PERMIT ,���T������ �����T '
;�:. , , , _ _ _.. .:
::: ._.:., ...:.
PERMIT NO.
BUILD �����3essN WOLFE RD #EPS4 REEVE KfJIGHT CONST 07090104 •
PERMIT LSSUE DATE
OWNER'S NAME:
LANDMARK—VALLCO 500 GIUSEPPE CT
SAMTARY NO. CONCROL NO.
�NE:
(916)786-5112
BUILDING PERMITINFO
ARCHITECT/ENGiNEER:
BLDG ELECT PLUMB MECH
� � � 0
i p � LICENSED CONIRACTOR'S DECLARATION JOb D0SCi1pL10❑
; v� I hcrc6y af[irm that I am liccnscd undcr provisions of Chap�c� 9(cammcncine
; Z� with Scction 7ocw) of Division 3 of �hc Busincss and Pro f c� iyt��e9c. ane my �icensc is REV I S I C N — REV I S E CM�.T WALL C ONSTRUC T I ON .
�� y in full Corce and effec G y( (�T
3 �z LicenscCl ���.�► ORIG #07040021
; �,, � Datc l (�f— — Contncmr
� ARCHiT6Ci'S DECLARATION
7 a a 1 undcrstand my plans shalt bc uscd as public recorcls
>yU
' w F' Liccnsed Prufcssional
"� < OWNER-HUII.DER DECLAAATION
� Q� 1 hcrcby atTirm Ihat 1 am excmpi Gum ihc Conlractars Liccnsc Law for the
p o (ollowing reason. (Scction 7031.5. Busincss and Profcssions Ca1c: Any city or rnunty
�,°, � which rcquires a permit to cnnswct, altcr, impmvc, dcmulish, or repair any structure
° Z y prior to i�s issuancc. also rcquires U�c applicant for such pertnil to filc a signcd sutcmcnt Valuation
- a �hat hc is liccnscd pursuan� to thc provisions o! ihc Conuactor's Liccnsc Law (Chaptcr 9 3q. Ft. Floor Area �
Y t �(commencing wi�h Scction 7000) of Division 3 oC �hc Busincss and Profcssions Cadc) or �
��� ihat he is ezempt thc+cfrom and �he bazis [or the allcgcd ezemptioa My violaCion a[
Secaon 7031.5 by a�ry applicant for a pecmit subjccts ihe applicant to a civil penalty of A Number Oceupancy Type
not more U�an five hundrcd dollars (5500). 3 1 6 2 � � 3 7.��
Q I, u ownc� of Aie property. or my employcu with wages az the'v sok compenvtion.
willdo�hcwork.andiheskuctureisnotintendcdorotCuedfarsak(Sec. Required Inspections
and Professions Code: 'It�e Conuacwfs License Law daes not apply to an owner of
propeny who builds ot improves thercon, and wha does such work himtelCor Uwugh his
own employees, provided that such improvements ace not intended or otCered for sale. i[.
however. Ne building or improvement is sold within ane year af rnmpletion, Ihe owner-
buiider will have the burden oC proving d�a� he did not huild or improvc [ar pmpnse of
salc.).
0 I, as awner of the property, am exclusively conuacting with limnsed rnnuactors W
conswct the projett (Sec. 7044, Business and Profcssions Cade:) 7Le Coatracwrs Li-
cense Law docs oo� apply w an owner of propeny wha builds or impmves the�on. and ,
who contracts Car such pmjec�s with a contnctar(s) liacued pursuant m ihe Contractofs
License Law.
❑ I am exempt under Sec. . B R P C for this �cason
Owner Date _. ,. _
WORKER'S COMPENSATION DECLARATTON
1 hcrcby �rm under penalty of perjury one o[ the fallowing declarationx
❑ I hs+e and wilt maintain a Ceni6caic of Consent to self-insure far Workefs Compen-
sation, as provided for 6y Section 3700 af [he Labor Code, far �he performance of U¢
work for which Ihis pertnit is isaucd.
❑ I havc and will maintain Worktr's Compensation Insunna, u requircd by Scaion .
3700 of thc Labor Codc, for thc per[ormmcc of �he wwk for w6ich �Ais pecmit is istued
My Worker's Compensation [nsurance camer and Poliry number are: '�
`/ ni�
Cartier��! r1[.�K ./t/�C� Policy No.: �
CERTIFiCATE OF EXEMPI70N FROM ORKERS'
COMPENSATIONINSURANCE
(f'his section irecd not bc completcd if the permit is [or anc hundred dallars (SI00)
or IessJ
I certi[y that in ihe performance of ihe work for which �his permit is issued, I stull irot
employ any person in any manner so u to become subject to Uie Workers' Compensatioa
Laws of Califomia. Datc
Applicant
NOTICE TO APPL]CAM: If, aftcr making ihis CcrtiGca�c of Excmption, you should
bccome su6jcct w thc Workcr's Compcnsation provisions oC thc Labor Codc, you muu
, O forthwith comply wi�h such pmvisions or this permit shall be dccmcd revokcd.
z "-' CONSTRUCTION LENDING AGENCY
� i—�i 1 herchy affirtn that there is a consuuction Icnding agenry Cor the performance uf
�� ihc wurk for which this permit is issucd (Scc. 309"/. Civ. C.)
W Q Lendcr's Namc
a z Lcnder's Address
J � 1 certify ihat I havc read this application and s�alc thal thc abovc infomuuun is . �
��'+ correc� 1 agree �o comply with all ciry �nd counry onlinances and sute laws relaung to
� J building conswction, and hereby authori�e rcpresenutives of �his city to en�cr upon Uic
above-mentioned property for inspecuon purposes.
'� W (Wc) agrce to save, indcmni(y and kccp harmless the City of Cupcnino against
`-' � liabilities, ud mcn�s, costs and ex nscs which ma �n an wa accruc a ainst said Cit
r-i V] J B P� Y� Y Y B Y
(„) Z in consequence of thc granting of lhis permit. Date �'- ���' �
�'" APPLICA U ERS DS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR ATI
ti� Re-roofs
Sign rc f pli UConuaaor Datc
HAZARDOUS MA7'ERIALS DISCL�SURE Ty� Of F.00f ��
Will thc applicant or futurc building accupanistore or handlc ha•rardous mucrial
az defincd by �he Cupertino Municipal Codc, Chaptcr 9.12, and U�c Hcalih and Safcty
ca� SecGon 25532(a)? ,,[ All roofs shall be inspected prior to any roofing material being installed.
❑Ycs ,�1N� ,
/ If a roof is installed without first obtaining an inspection, I agree to remove
Wi11 thc applicant or Cuturc building occupan� usc cyuipmcnt or deviccs wh�h
cmit harardous air conuminan�s as cicfincd by �he Bay Area Air Qualiry Managcmcnt all new rr.aterials for inspection.
��su;��?
Q Ycs , �No
I havc rcad Uie hvarCcws amrials reyuircments undcr Chap�er6.95 of ihc Califor-
nia Hcalth & Safe . Secti 25505, 25533 and 25534. I u�crstand that iC �hc 6uilding
docs n i t�y vc a �c � that it is my nsiAiliry to noril'y Uu aaupant nf Ihc
rcyui n must o�priorwi «orec�,;rMa�ora���ry. Signature ofApplicant Date
All roof coverings to be Class "B" or better
ncr or authorizc gcn� Datc