07020140CITY OF CUPERTINO 7�7y� A
BUILDING DIVISION PERMIT C�l�T1tAC'
BUILDING ADDRESS:
10123 N WOLFE RD J T CONSTRUCTION
OWNER'S NAME:
CUPERTINO SQUARE LLC 1720 OCALA AVE.
PHONE:
(408)272-4570
ARCHITECT/ENGINEER
Z LICENSED CONTRACTOR'S DECLARATION
F I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
x a in full force and effecL
License Class Lie. #
_ Date_ Contractor
ARCHITECTS DECLARATION
za I understand my plans shall be used as public records
yU
t in Licensed Professional
�
OWNER -BUILDER DECLARATION
_J I hereby affirm that 1 am exempt from the Contractors License Law for the
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
Z r 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
(commencing with Section 7000) of Division 3 of rhe Business and Professions Code) or
.. 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
not more than five hundred dollars (S500)_
Q I, as owner of the property, or my employers 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 Law does 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 IV did not build or improve for purpose of
P*"s owner of the property, am exclusi)ely contracting with licensed contractors to
construct the project (Sec. 7044, B in and Professions Code:) The Contactors Li-
cense Law docs not apply to an Li-
;f,
otproperty who builds or improves thereon, and
who contracts for such projec a/omactor(s) licensed pursuant to the Contractors
License law.
Q 1 am exempt
ON DECLARATIO
I hereby affifiry'uo penalty of perjury one of the following declarations:
Q 1 have and will maintain a Certificate of Consent to self -insure for Workers Compcn-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
Q I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, far the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
(Phis section need not be complctc�ffihc permit is for one hundred dollars ($100)
or less.)
I certify that in the performanceork for w ch this permit is issued, 1 shall not
employ any person
this Ccnificatc of Exemption, you should
become subject to the W s Campcnsadon provisions of the Labor Code, you must
z forthwith comply with su provisions or this permit shall be deemed revoked.
. 0
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.)
a Q Lender's' Name
z Lender'sAddress
0 1 certify that I have read this application and state that the above information is
— correct. I agree to comply with all city and co ty ordinances and state laws relating to
Ubuilding construction, and hereby authorize presentatives of this city to toter upon the
y W above-mentioned properly for inspection ores.
r LL (We) agree to save, indemnify keep harmless the City of Cupertino against
fA liabilitics,judgments, costs and which may in anyway accrue against said City
Z in consequence of the grant' o this rmit.
APPLICANT UNDERS N A D WILL C PLY WITH ALL NON -POINT
SOURCE REGULATi - z 3 (J l�
Signature of ApplicanbXontact r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contafLLha
cd by the Bay Arca Air Quality Management
District?
❑ Yes
Ihave read thehasrequirements under Chapter 6.95o(the Califor-
nia Health & Safety Code25533 and 25534.1 understand that i(thc building
does not currently ha my raponsih.lity t notify the occupant of tits
requirements which uissuance of a Cc(�Vupat2eyr-)
Owner or authorized accni Date
PERMIT NO.
07020140
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
Job Description
TI—FOOD COURT: 39714' E/M/P. 2 NEW RESTROOMS, 1
FREIGHT ELEVATOR, 1 SKYLIGHT, 3 NEW AC
UNITS—SANITARY APPRV FOR T.I. ONLY, DOES NOT
Sq. Ft. Floor AreaValuation
$1100000
31620063`E' Num
Required Inspections
Re -roofs
Type -of Roof
Occupancy Type
Date �1, 2 Y
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better