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07060224CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO: 07060224 10291 S DE ANZA BLVD (359 17 00 1) OWNER'S NAME: DATE ISSUED: 07/24/2007 OWNER'S PHONE: RHONE NO: LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class Lic. # Contractor Date —BLDG —ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing NTECH _ RESIDENTIAL COMMERCIAL with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. JOB DESCRIPTION: REPLACE (E) HAVAC UNIT/ADD NEW HVAC UNIT. NEW I hereby affirm under penalty of perjury one of the following two declarations: HVAC SHALL NOT BE VISIBLE TO PUBLIC VIEWS. 1. 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. 2. I have and will maintain Worker's Compensation Insurance, as provided for by , Section 3700 of the Labor Code, for the performance of the work for which this% - - permit is issued. -' - 5q. Ft Floor Area: Valuation: $12500.00 APPLICANT CERTIFICATION 1 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 APN Number: Occupancy Type: and state laws relating to building construction, and hereby authorize 359 17 001 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 PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point WITHIN 180 DAYS OF PERMIT ISSUANCE OR source regulations per the Cupertino Municipal Code, Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date Issued by: Le ac Date: 07/24/2007 OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE -ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed. If a roof is n. I, as owner of the properly, or my employees with wages as their sole installed without first obtaining an inspection, I agree to remove all new materials for compensation, will do the work, and the structure is not intended or offered for inspection. sale (Sce.7044, Business & Professions Code) 2. I, as owner of the property, am exclusively contracting with licensed Signature of Applicant: contractors to construct the project (Sec.7044, Business & Professions Code). Date: I hereby affirm under penalty of perjury one of the following three declarations: 1. f have and will maintain a Certificate of Consent to self -insure for Worker's ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance, as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the Section 3700 of the Labor Code, for the performance of the work for which this California Health & Safety Code, Sections 25505, 25533, and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the s. I certify that in the performance of the work for which this permit is issued, I Health & Safety Code, Section 25532(x) should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous Worker's Compensation laws of California. If, after making this certificate, of air contaminants as defined by the Bay Area Air Quality Management District I ekemption, I become subject to the Worker's Compensation provisions of the will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date: I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct. I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction, and hereby authorize representatives of this city of work's for which this permit is issued (Sec. 3097, Civ C.) to enter upon the above mentioned property for inspection purposes. (We) agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code, Section 9.18. 1 understand my plans shall be used as public records. Signature Date Licensed Professional CITY OF CUPERTINO f " f� E,i' 1 QR IN DIVISION PERMIT BUILDING BUILL�r��itEs DE ANZA BLVD TBD TO BE DETERMINED PERMIT NO. 07060224 SANITARY NO. CONTROL NO. ARCHITECTIENGINEER: 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 (commeaeng with Section 7000) of Division 3 of the Business and Professions Code, and my license is REPLACE (E) HAVAC UNIT/ADD NEW HVAC UNIT. NEW in full force and efftFL License: Class uc.y AC SHALL NOT BE VISIBLE TO PUBLIC VIEWS. — Dale C _C� Contractors t ARCHITECTS DECLARAT143N I understand my plans shall he used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following mason. (Section 7031 S, Business and Professions Code: Any city or county which requires a permit to concoct, alter, improve. demolish, or repair any structure prior to is issuance, also requires the applicant for such permit to file a signed statement Contractor a License Law (Chapter 9 Sq. Ft. Floor Area Valuation Nat he is licensed pursuant to the provisions of the 12 5 0 0 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by arty applicant for a permit Subjects the applicant to a civil penalty of Number Occupancy Type not more than five hundred dollars (S500). 35917001 ❑ L as owner of the property, or my employees with wages as thew sole compensadon, will do the work, and the structure is not intended or offered for sale (Sec 7044, Business Required Inspections and Professions Code. -The Contractors License Law does not apply to an owner of q 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 We ❑ 1, as owner of the property, am exclusively conuacting with licensed contractors to construct the project (Sec 7044, Business and Professions Code:) The Conaacmr's L.i- ecase 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 Contactors License Law.- . ❑ 1 am exempt under Sec , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I 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 ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is Isarred My Workeh ompensai on In sua ice carrict and Policy number am: Carrier.�� fr Policy No.: W ' t r \ 00 CERTIFICATE OF EX PTLON FROM WORKERS 1 b 77 t COMPENSATION INSURANCE l ('his section need not be completed if the permit is for one hundred dollars(S 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 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 forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constroction lending agency for the performance of y the work for which this permit is issued (Sec, 3097, Civ, Q Lenders Name Lenders Address r I eenify that I have read this application and state that the above information is " correct. 1 agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorirt representatives of this city to enter upon the ahovc-mentioned property for inspection purposes. 4 (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, in way accrue against said City judgments, toss and expense which may any in consequence of the granting of this permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: iZ r ONS. Re -roofs tare o IicuWContrsctor Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof . Will the applicant or future building occupant Store or handle hazardous material . as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety Code, Section 25532(a)? No All roofs shall be inspected prior to any roofing material being installed. ❑Yes If a roof is installed without first obtaining an inspection, I agree t0 remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area AL Quality Management all new materials for inspection. District? l ❑ Yes 1 have read the hazardous materials requirements under Chapter 6.95 of theCalifor- nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building does not currently have a ternnt that it is my responsibility to notify the occupant of the requirementa which be met prior ro issuance of a Certificate r Oee:upaney. Signature of Applicant Date "B" ' Al] roof coverings to be Class or better Own nl Datc