08010137 CITY OF CUPERTINO � � �
BUILDING DIVISION PERMIT
PERMIT NO.
BukL�ir�G1A�° �N WOLFE RD 2121- GLOBAL MECHANICAL 08010137
OW ft�tE:21:42, 2t46PERMIT ISSUE DATE
CUPERTINO SQUARE LOC I PO BOX 2698 01/23/2008
PHONE: (415) 203-3640 SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Q O 0 LICENSED CONTRACTOR'S DECLARATION
mC I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Jab Description
zW with Section 70M)ofDivision3oftheBusinessandProfessionsCo and my license is DEMO OF 5 STORES, INTERIOR ONLY(2121, 2122, 2123
n
Ca in full force and f 6'7 l O�i
j 2 Z License lass Z Lic.R -k, 2142, 2146)
3 t-❑ Date 1 Contractor '
gw ARCHITECTS DECLARATION
ill,
d a I understand my plans shall be used as public records
7,U
O
w Licensed Professional
n yr g OWNER-BUILDER DECLARATION
<� I hereby affirm that 1 am exempt from the Contractor's License Law for the
%p O 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
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
SEC F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $37500
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of umber OCCLl
not more than five hundred dollars($500). 3 16 2 0 0 3 7 1 Occupancy Type
❑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,Business
and Professions Code:The Contractor's License Caw dots not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
lawn employees,provided that such improvements we 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 ar improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(See.7044,Business and Professions Code:)The Contractor's Ll-
tcnse law dots 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 Contractors
License Law.
❑1 am exempt under See ,B&PC for this reason
Owner Date ,
WORKER'S COMPENSATION DECLARATION /
i
I hereby affirm under penalty of perjury one of the following declarations: -
❑I have and will maintain a Certificate of Consent to self-insura 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.
❑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 Compensation 1,�)surra�nce carrier and Policy numher a1 1
✓ -A R Policy No.x ��� (l 7 y
CERTIFICATE OF EXt FTION FROM WORKERS'
COMPENSATION INSURANCE
(Ihis section need notbecompleted if the permit is faronc hundred dollars(EI00)
or less)
1 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
become subject to the Workers Compensation provisions of the labor Code,you must
Q revoked.
forthwith comply with such provisions or this permit shall be deemed red.
z � CONSTRUCTION LENDING AGENCY
...�.
(� 1 hereby alGrm that Nerc is a corswcdnn lending agency for the performance of
G: the work for which this permit is issued(Sec.3097,Civ.C.)
W QLender's Name
0 zLender's Address
U 0 1 certify that I have read this application and state that the above information is
LL toren.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hemby authorise representatives of this city to enter upon the
W
ahove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless We City of Cupertino against
acel liabilities,judgments,costs and expenses which may in anyway accrue against said City
U 'Z in consequence of the grantfn • permiL
r APPLICANT UNDE DSA WILL COMPLY WITH A72N.0g7ooiNT
IIssued by: 12�cade Date
SOURCE REGU Ol
Re-roofs ice.
Signature of Applicant/Contractor D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cuperdoo 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.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,.I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes U-1 o-
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Haa1N&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a that it is my responsibility to notify the occupant of the
requirements which m rior to issuance:of a Ccniftcam of Occupancy. Signature Of Applicant Date
Owner or authorized agent Doc
All roof coverings to be Class"B"or better
08010137
CITY OF CUPERTINO L,*,z 443
1 '' DEMO
";D
C11111ll OF to
CUPS TING) PERMIT APPLICATION FORM _P � 111
APN# o %2 Date:
SI L ^ 2 _, ;/� l 1 v8
Building Address: 03/ 23,Q./y�� 1 y
CA
Mailing Address (if different—from building address):
Owner's Name: Phone:
cueEr-Foo S utq>z-E L x-) C qoo -�-71 --i o,� I
Contractor: Phone : y j Zo 3 K 4.LlJ
GI t. tC_ Fax: 7o ? -- Z �'SZ7
Contractor License #: 6?1 o,5
Cupertino Business License #:
Contact: 1� L Phone: y f _ Z o3 _3 q�v 2h S
Fax: 0 '1 — 2`'_ �5' 2.
Residential ❑ Sq Footage Commercial Sq Footage
Job Description:
Valuation: .3 7, S00
Attach Green Building Checklist to demo plans.
Ouantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
iBSEISMICRE Seismic Residential B
1DEMOCOM Demo-Commercial B 1COMML-DEM
1BSEISMICOM Seismic Commercial B
1BUSLIC Business License B
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