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MY OF CUPERTINO
DIVISION PERNIIT
T+Ci:���NF
BUILDING
BUILDING ADDRESS:
PERMIT NO.
19750 SPEVENS CREEKCONEX
DEVELOPMENT
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
A O. CONTROL NO.
(323)344-1212
ARCHr ECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
9
Job Description
1 hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Division 3 of the Business and Profession Code, and my license is
in full force and effect cl 3 i2
REV ADD ' L EQUPMNT ANCHORG (DELTA4) SHWN ON
License Class - Corar
. Conractor
—�
PLN(PHASE II AREA) -ORIG #08040179
ARCH1TECrS DECLARATION
I understand my plans shall be used az public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Profession Cale: Any city or county
which mquirea 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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$300
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars (5500).
36906008 . 0 2
C]1, az owner of the property, or my employers 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 Profession Code: The Contnemrs License Law docs 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
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Conuaetor's Li.
cents Law dors 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.
❑ I am exempt under Sec , B & P C for this reason
(�Q
Owner ! �f l � . �� / / ��st Date
'WORKER'S
COMP S ON DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate 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.
❑ 1 have and will maintain Worker's Compensation Insurance, az required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
'
My Worker's Com Fnad Insurance amcr and Polity
/E e
X
Carrier. - ce7l t Eolicy No.:
IC E 1 ATE OF EX PT10N FROM W ORK RS' 1
COMPENSATTON INSURANCE
(This section reed not be completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so at to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
_
become subject to the Worker's Compensation provisions of the labor Code, you must
forthwith comply with such provision or this permit shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
I hereby affirm that there it a construction lending agency for the performance of
the work fur which this permit is issued (Sec. 3097, Civ. Q
Lender's Name
,
Lender's Address
1 certify that 1 have read this application and state that ft above information is
'
correct 1 agree to comply with all city and county ordinances and state laws relating to
building convection, 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' sy way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WIL PLY WITH ALL NON -POINT
n
Issued by:S Date(i �
SOURCE REGULATIO
.
Re -roofs
Type of Roof
-(&W—
Da
H OUS MATERIALS DISCLOSURE
Will the appli Car future building Occupant store or handle hazardous material
/
as defined by the Cupertino Munic' al Code. Chapter 9.12, and the Health and Safcty
Code.
Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Ya No
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
emit hazardous air contamina is defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Ya NO
1 have mud the hazardous materials requirements derChapicr6.95 of the Califor-
nia Health & Safety Code, Section 25505, 25533 and .1 understand that if the building
does not currently have a at tis my •bility to notify the occupant of the
requirements which be m In iss f a Certificate occupa
f Occupancy.
Signature of Applicant Date
- . o
All roof coverings to be Class's" or better
Owner,64urni0k,agent
am
PM
CITY OF
CUPEKrINO
CITY OF CUPERTINO
REVISION/DEFERRED
PERMIT APPLICATION FORM
op/moo vii
APN # / 9 D O O�`� 0
l0
Date:
�d
Original Permit #: o
06 0617q
Building Address: `
M--7 Sb ��PtLS CP-e�
Mailing Address (if different from building address)
Owner's Name:
Phone #:
Contractor:
Phone: e213 =x.;!5'
C3�� 34A-- ( of Z
Fax:
Contractor License
Cupertino Business License #:
Contact:
Phone: 47 Z I
Fax: +7'
Building Permit Info: (5t
Bldg Elect ❑ Plumb ❑ Mech ❑
Residential ❑ Commercial ❑
Job Description:
Tr o►� pl— �� t �M�� � 1� c�?.�! � �$7�1�P� `�- I �{,(�t�ln�
dpi
ori 'P43- (WPEr—
Is the project in the Wildland- Urban Interface Fire Area? Yes 0 No
Type of Construction (Usage Class):
* ccupancy Type:
1-A, 1-B ❑ , II/III/V-A ❑ II/III B, IV -HT, V -B
Valuation (cost of project):
Project Size: Express Standard Large Major
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.builditjlreen.org
Revised 10/01/08
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