03100095a
CUPEkTINO
CITY OF CUPERTIN
DEMO
PERMIT APPLICATION FORM
APN #
Bldg Permit Fees
BUILIDNG
Date:
Building Address:
BSEISMICOM
Seismic Commercial
BUILIDNG
Owner's Name-,
-PO
BSEISMICRE
Phone
4
Contractor:
License
Contact:
Plan Check Fee
BUILIDNG
Phone
Applicant/Contractor:
Building Permit Info:
Bldg
Elect Plumb
Mech
Job Description:
Residential:
'o,
Commercial:
Sq.Ft. Floor Area: s
4,0 0 U 6?
$/Sq.Ft.:�
Business License
BUILIDNG
Architect/Engineer:
Valu ion:
Type of Construction:Occupan
Qty. if
Am)li able,
ii o
Fee ID
Fee Description
Fee Group
BPERMFFE
Bldg Permit Fees
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
BSEISMICRE
Seismic Residential
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BUSLIC
Business License
BUILIDNG
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CITY OF CUPERTINO
BUILDING DIVISION PERM
CONTRACTOR INT'ORMA )N
BUILDING ADDRESS:
PERMIT NO.
03100095
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
DEMO
License Class Lic. p
Date contractor
CONTRACTOR: NAV I CO INC (#24836)
ARCHITECTS DECLARATION
,
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am esempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit a, construct, alter, improve. demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuatlo
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
0 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
3�11}}er 0 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work himself or through his
704 - DEMO
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale,).
❑ 1, as owner of the properly am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li -
cerise Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such pmjects with a contractor(s) licensed pursuant to the Contractor's
License Law.
[g 1 am exempt under Sec:', . B & P C for this reason
Date �CJ o '�
YY WORKEIF'S COMPENSATION DF�I,ARATION
I hereby following declarations:
affirm under penalty - perjury one oPth
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker'sCumpcn-
sation, as provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhissection need not be completed if the permit is for one hundred dollars ($IIX))
or less.)
I certify tha>ic 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—
al"
�es
licanl• \c , ,,,�;
AAp
t l'ICE TO APPLICANT: If, after making this Certificate of Exemption, you should
A'
become subject to the Worker's Compensation provisions of the Uhor 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 construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 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 conswction, 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, comsand expenses which may in any way accrue againstsaid City>—
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in consequence of the granting of this permit.
(y°
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/'17
Issued by:Date
$CJURqE REGULr PIONS.
z
�. 1c'1J 3/6n ?
Re -roofs
Type of Roof
'Signature of Applicant/ContractorDalc '
MATERIALS DISCLOSURE
Will du 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, Scction25532(a)?
'�
All roofs shall be inspected to any roofing material being installed.
❑ Yes No
prior
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 contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District? /
❑ Yes Q No
I have read the hazardous materials requirements under Chap(cr 6.95 of dtc Califor-
niaHealth & Safety Codc, Sccdons 25505, 25533 and 25534. I understand that if the building
docs not currently have a tenant, that it is my responsihilily to notify the occupant of the
requirements p
which must be me rior to issuance of a Certificate of Occupancy.
--� �,
Signature of Applicant Date
"B"
�
Owner V
All roof coverings to be Class or better
ur authorized agent Date