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CITE' OF CUPERTINO
7
BUILDING DIVISION PERMIT
CdITRACTUR t�URMT�ON :,.'
BUILDING ADDRESS:
PERMIT NO.
20530 STEVENS CREEK BLVD
TBD TO BE DETERMINED
07120031
OWNER'S NAME:
PERMIT ISSUEDATE
MARDESHICH CROSSROADS
12/05/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITEC IENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter
Job Description
1 hereby affirm that I am licensed under provisions of 9 (commencing
with Section 70W) of Division 3ofthe Business and ProfeuionsCode , dmylicenscis
SIGN INSTALLTN; ILUMINATNG CHANNEL LETTER. STREET
L enseClull eanderrect
License Clas�j Lic. N
GRAPHICS INC. DBA DELTA SIGNS PD BSL 12/05/07
-lomraclor
ARCHITECCS DECLARATION
110
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
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 te its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the of the Contractor's License Law (Chapter 9
Sq. Ft. Floor AreaValuation
pursuant provisions
(commencing Section 7000) Division 3 of the Business and Professions Code)
$1500
with of or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 5 9 0 8 018 � umber
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
net more than rive hundred dollars ($500).
❑ 1, 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 dors not apply to an owner of
q p
property who builds or improves thereon, and who does such work himself or through his
own employers, 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 property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense Law docs 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 Contractor's
License Law.
C]I am exempt under Sec , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I 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 issued.
'
My Worker's Compensation Insurance carrier and Polity number am:
Carrier. Polity No.: gz, - 0,9 Qj /66
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if ibe permit is forane hundred dollars ($100)
or less.)
I eenify 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 Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUC71ON 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
'
Lenders Address
1 certify that 1 have read this application and state that the above information is
corecL I agree to comply with all city and county ordinances and state laws relating to
building construction, 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, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICAMyiUNDERSTANDS D WILL COMPLY WITH ALL NON -POINT
Issued by: Date _f
SOURCE ULATIONS
111107
Re -roofs
Signature of ApplicanUContraclo 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)7
❑ Yes o
I(,{It
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or futum building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
.I
all new materials for inspection.
District?
F1 Yes
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant, tha t is my responsibility to notify the occupant of the
reyuiremc hich mull t p Fir ice issuance of a Certificate of/O/ccupas
Signature of Applicant Date