07060055f9 Z
00
IUU
Z Lu
i�H
uj
9 U U
aU.
f-
0 n
urn<r
'p0
try
zr
CITE' OF CUPERTINO
BUILDING DIVISION PERMIT
r
C�1TC'f? IQR4TIQ1.
BUILDING ADDRESS:
PERMIT NO.
19640 STEVENS CREEK BLVD
TBD — TO BE DETERMINED
07060055
OWNER'S NAME:
PERMIT ISSUE DATE
EVERSHINE VI L.P.
12/04/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Pro(c iops CQd api�py license is
DEMO (E) COMMERCIAL BLDG.
in full force and effect tom[(-J'jt(j/� 8 /
License Class Lie. S
Date _ Contractor
ARCHI'IEC 'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Profusions Code: Any city or county
which requires a permit to consuuct, alter, improve, demolish, nr repair any structure
prior to 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 Area
Valuation
pursuant provisions
(commencing Section 7000) of Division 3 the Business and Profusions Code)
$60000
with of or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 6 9 0 6 0 0 9 `.d'ff
O
Occupancy P Y T YPe
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofNumber
not more than rive hundred dollars (M).
❑ I, as owner of the property, or my employers with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered forsale (Sec, 7D44, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
q P
property who builds or improves thereon, and who does such work himself or through his
own employ=, 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.).
❑ I, as Owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 7044• Business and Professions Code:) The Contractors U.
cense law does not apply to an owner of property who builds or improves thereon. and,
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
❑ I 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:
❑ 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.
❑ 1 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 Wo r s Co p nsadon in rance arrt`c_r_and Polity number e:
Carrier. V 4tfrrtU1st9toliryNo.:
CERTIFICATE of EXEM ON FROM WORKEj(S'
COMPENSA71ONINSURANCE
(This section need not be completed if the permit is for one hundred dollars (S100)
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. Dam
Applicant
NOTICE TO APPLICAM: If, after making this Certifioam 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.
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 (See. 3097, Civ. C.)
Lenders Name
'
Lenders Address
1 certify that I have read this application and state that the above information is
'
coffecL I agree to comply with all city and county ordinances and slate laws relating to
building construction, and hereby authorize representative of this city to enter upon the
above-mentioned property for inspection purposes.
save, in nify and keep harmless the City of Cupertino against
costs d e pensu which may in any way accrue against said City
g ng o this permit. LL COMPLY WITH AL N N -POINT
qPL%1CRST.ND
Issued by: Date
� O
Re -roofs
c�
Si nature of pplicawcortrasir Dam
HAZARANOUS 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(x)?
C] Yes 1146-
All roofs shall be inspected prior to any roofing material being installed.
Will future
If a roof .is installed without first obtaining an inspection,agree to remove
the applicant or 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?
❑Yes fu
1 have read the hazardous materials mquimmen der Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505,25533 and 34.Iunderstand that ifthebuilding
docs not currently have a tenant, that it is my risibility to notify the occupant of the
requireme met ' to cc of a Certificate of Occup
.e?
Signature of Applicant Date
A11 rr%r%f rnvPnnac to ha (`lace "R" — I.etse-