11070023 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:OFOOTHILL&280 CONTRACTOR:CAPITAL TOWER AND PERMIT NO:11070023
COMMUNICATIONS
0—NER'S NAME: CALTRANS13330 AMBERLY RD DATE ISSUED:08/02/2011
L. ,PER'S PHONE: 5102864444 WAVERLY,NE 68462 PHONE NO:(404)786-3333
❑ LICENSED CONTRACTOR'S DECLARATION
/r {� BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class fr1"3 (<Li Lic.# ��() �,� � �" r`
MECH " ("RESIDENTIAL COMMERCIAL
Contractor(11- Jam,Qf' Date - `
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE AND REPLACE EXISTING EQUIPMENT CABINET
(commencing with Section 7000)of Division 3 of the Business&Professions INSIDE-OF LEASE AREA
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by Sq.Ft Floor Area: Valuation:$4000
Section 3700 ofthe Labor Code,for the performance ofthe work for which this
perml'is issued.
APN Number: Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 2$0 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-poi s urce regulations perAhe Cope no Municipal Code,Section /
Signature
9.18. Issued by;/ -� Date: '
a Z-�-
i nature �`.`�/ —p to 1
�
U OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material beiig installed.if a roof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:_ Date:
Business&Professions Code)
I,as owner ofthe property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's i have read the hazardous materials requirements under Chapter 6,95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation insurance,as provided for by Safety Code,Section 25532(a)should i store or handle hazardous material.
Section 3700 ofthe Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District i will
p maintain compliance with.the Cupertino Yunicipall Code,Chapter 9.12 and the
I certify that in the performance ofthe work for which this permit is issued,I shall health& afety CodelSe�;rZ5 533,and25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws ofCalifornia If after making this certificate ofexemption,I Owe o' authori become subject to the Worker's Compensation provisions ofthe Labor Code,I must te: ';_
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.1 agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
mnify and keep harmless the City of Cupertino against liabilities,judgments,
.and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
k-rmiting of this pcmrit,Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section (understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date