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CITY OF CUPERTINO
DIVISION PERMIT
W.
BUILDING
BUILpI(�C�ppj IkEVENS CREEK BLVD #208
jNAME:
TBD - TO BE DETERMINED
PERMIT NO.
07110030
OWNER'S
PERMIT ISSUE DATE
MENLO EQUITIES
11/29/2007
')NE:
SANITARY NO. CONTROL NO.
ARCHITEC IENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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
MDFY EX S TNG CEI LNG FOR BTR ACU STC r ADJ S T S PRNKLR
in full force and effect
License Class Lic.0
SYS AS DEEDED
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (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
License Law 9
Sq. Ft. Floor Area0000
Valuation
that he is licensed pursuant to the provisions of the Contractor's (Chapter
1
(commencing with Section 7000) of Division 3 M the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SSW).
31649009.
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are 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
sa ).
I, as owner of the property, am exclusively contracting with licensed contractors to
nstract the project (Sec. 7044. Business and Professions Code:) The Contractor's U.
tense 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 Ute Contractor's
License Law.
[3 1 am exempt under Sec. B k P C for this reason
Owner Date U
RKE 'SCO ENSATION ARATION
_-Jai+
I hereby affirm under ty of perjury one o following declarations:
I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 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 Workers Compensation htsurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section meed not be completed if the permit is formic 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 man so as to bee subject to the orkt:rs' Co pensation
Laws of California. Da
Applicant
NOTICE TOA ng this Certifies f Exemption, you should
become sub a Worker's Co don provision the Labor Code, you must
forthwith comply with such provisidrA or this permit sh 1 deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction (ending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
j 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 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
j liabilities, judgments, costs and expenses which may in any way accrue against said City
' in consequence of the granting of this permit
NDERSTA�ANb L OMPLY WITH ALL NON -POINT
4 APPLICAREGULATIQNS�-/
Issued by: Date
SOURCE
/Re
I
-roofs
Signuure ppliesnt/Con r Dad
HAZARDOUS MATERIALS EUCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as derined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes 7Q(o
/ �
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management
all new IT aterials for inspection.
.Astrict?
)�LNo
❑ Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health tit SafctyCodc, Sections 25505.25533 and 25534.1 understand that ijthe building
dors not currently have ant, th it isrisibility to notify the occupant of the
requirements be met ' r u of a Cerificato of Occu�'"`�'
ignature of Applicant Date
(pato a
All roof coverings to be Class "B" or better
Owner or authorized agent