07020113 CITY OF CUPERTINO g. ` £Y
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BUILDING DIVISION PEk�;* d I ..
c a >.: ?10r
PERMrr NO.
"'L :ux< :Fees:
5lr� / Y'8RANADA AVE TBD - TO BE DETERMINED 07020113
OWNER'S NAME: PERNMISSUEDATE
03/11/2008
PHONE: SANITARY Na CONTROL NO.
ARCHrrECTIENGINEML, NEW 2 STORY UNIT-1ST FL BL.DG BUILDING
PUJMB MECH
p p LICENSED CONTRACTOR'S DECLARATION 242 ' r
i 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing •^'^^ - Job Description
7�. with Section 7000)of Division 3 of the Business and Professions Code,and my license is
h in full face and effect
h, Z License Clan Lk-N
Date Contracfar
ARCHITECTS DECLARATON
i I understand my plans shall be used as public records
ire
.a
n, Llcaued Professional
'a OWNER-BUILDER DECLARATION
J<F I hereby affirm that 1 am exempt from the CDntraaoe5 License Law for the
a O following reason.(Section 7031.5.Business and Professions Cox:Any city or county
3$� which requires a permit to construct.alter.hnprove,demolish,or repair any strvUurc
z y prior to its issuance,also requires the applicant for such permit to file a signed statement
`S^< that be Is licensed pursuant to the provisions of the Conuacmrl License Law(Chapter 9 Sq.Ft.Floor Area Valuation
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that ire is exempt Orrefrom and the buts for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number OCCu anC
not more than five hundred dollars(S500)_ P y'l�Pe
❑L,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 Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himsel or through his
row employes,provided that sucb 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
L as owner of the property.ata exclusively contracting with licensed contractors to
consuut the project(Sec.7044,Business and Professions Code:)The Contractors L i-
emnse 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 the Contractors
License Law.
❑1 am °ypytJern Sec / .B k P C for Oda reason
Ownrr`j;G —Date
WORKER'S COMPENSA-nO DECLARATION
I hereby affirm under penalty of perjury one of One following declarations:
❑I have and will maintain a Certificate of Consent to self-insu a for Walter's Compen-
sadon,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 Workers Compensation lnsurance,u required by Section
3700 of the Labor Code,for the performance of the work for which this permit is Issued ,
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need 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,i shall not
employ any person in any man sou become subject to the Workers'Comperrsation
Lawn of Cgmna Da `S
NOTICE of Exc lion,you should
become subject to the Workers Compensation provisions of the Labor Codc,you must
O forthwith comply with such provisions or this permit shall be deemedd revoke
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
Yc .> the work for which this permit is issued(See.3097,Civ.C.)
QLenders Name
= 2 Lenders Address
;J 0 I certify that I have read this application and state that the above information is
Hcorrect I agree to comply with all city and county ordinances and state Ire relating to
(J building consuvcdon,and hereby authorize representatives of this city to ester upon the
Uabove-mcodoned property for inspection purposes.
r (We)agree to save,indemnify and keep harmless the City of Cupertino against
r rn liabilities,judgmwls,costs and expenses which may In anyway accrue against said City
J 7 in consequence of the granting of this permit
G�7 APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON-POINT Issued by: Date
CE ULATIONS.
'_' - _06O ) Re-roofs
Date
HAZARDOUS MAIIAIALS DISCLOSURE TI pe of Roof
Will One applicant or future building occupant store or handle hazardous material as dermed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes �tao
Will the applicant or future building occupant use equipment a 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 Au Quality Management all new materials for inspection.
District?
❑Yes o
I have read the hazardmu mate ials requhcmcns under chapter 6.95 of the Califor-
nia Health do SafctyCode,Sections 25505,25533 and 25534.1 understand thatif the bwlding
does not currently have a tenant that it is my responsibility to notify the occupant of the
Signature of Applicant Date
All roof coverings to be Class'r�T 'or better
er a authorized agent Date g '