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03110074CITY OF CUPERTINO BUILDING DIVISION ��i;�Nj -¢�� �7 'W-UN �t� V���` - N, �N BUILDING ADDRESS: MENEMSHA DEVELOPMENT GXOUP PERMIT NOO 3 110 0 74 19220 STEVENS CREEK BLVD OWNER'S NAME: 5525 S. DOUGLAS ST. PERMIT ISSUE DATE H & R BLOCK 11 14/2003 PHONE: (310)343-3430 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: 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 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is injull force nt f est• ,� e ClL1C �y�j LiceDale_ T I — — PART I WALLS 11-12 �Tt, Contractor 1 t ARCHITECTS L RATION I d d and my plans shall be used u lic records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License Law for the following reason. (Section 7031.5, Business and Profess ons Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure $18690 prior to its issuance, also requires the applicant for such permit to rile a signed statement thathe is licensed pursuant to the provisions of the Contractor's License Law (Chapter9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 37506007.00 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type P Y YP Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($500). ❑ I, at 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. 7D44, 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 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 Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and , who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors License Law. ❑ 1 am exempt under Sec. , B & P C for this reason Owner Dale 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 Workers Compen- sation, as provided for by Section 37DO of the Labor Code, for the performance of the work for which this permit is issued. J] I have and will maintain Worker's Compensation Insurance, as required by Section of the Labor Code, for the performance of the work for which this permit is issued. y Worker's Compensation Insurance carrier and Policy number are: (j Carrier.Y'1a P -0y No.- 2C ai LAq 501 ` 1 CERTIFICATE OF EXENU40N FROM WORKERS' COMPENSATION INSURANCE , (This section need not he completed if the permit is for one hundred dollars ($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 Workeri 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 Ibis 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.) L.ender's Name L-ender's Address I certify that I have read this application and state that the above information is correcL I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorise representatives of this city to enter upon the ahovc-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 anyway accrue against said City in consequence of the granting of this permiL ,1 APPLI ANT UNDERSTAN f AND WILL COMPLY WITH ALL NON -POINT Issued by: Date C RE ULATIONS, Re -roofs Type Of Roof , z5k ,x11 �� SigilatureApplicant/Contractor Dale HAZARDOUS MA IALS DISCLOSURE Will the applicant or future building upant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed. ❑ Yes �No 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 Area Air Quality Management all new materials for inspection, District? - ED Yes EfNu 1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor. nia Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that if rbc building does not currently have a tenant that it is my responsibility to notary the occupant of the T ruts which must „ r o issuance of a Cerifrcam of Occupancy. Signature of Applicant Date -- �' All roof coverings to be Class "B' or better Owner or a horixed agent ate LOO �zW -may Z S ma 20. COQ nCp� kml+ —z> r a - CITY OF CUPERTINO BUILDING DIVISION PERM4���`& 4.���y�����Fr�� MENEMSHA DEVELOPMENT GROUP PERMIT "003120106 BUILDING ADDRESS: 19220 STEVENS CREEK R T,�m OWNER'S NAME: PERMIT ISSUE DATE H & R 13LOC PHONE: SANITARY NO. CONTROL NO. (310)343-3430' 10 3 3- ARCHITECT/ENGINEER ARCHITECT•/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 LICENSED CONTRACTOR'S DECLARATION ' Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing .lob with Secti n 00U) of Division 3 of the Business and ro shuns Code, and my license is imm'fo-amdefet. REVISION --IN HOUSE USE ONLY License ass Lic.N Date , - -/-' Contract 1 NO NEW PERMIT 403110074 ARCHITECTS DECL N .ISSUED/ORIG. I understand my plans shall he 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 703 L5, Business and Professions Code: Any city or county . which requires a permit to construct, alter, improve, demolish, or repair any structure prior ht its issuance, also requires the applicant for such permit to rile a signed statement Sq. Ft. Floor Area Valuation that he is licensed pursuant to(he provisions ofthe Contracwr'sLicense Law (Chapter9 $31 - (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 ' APN Number 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, 37506007.00 - 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 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.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors. to - construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense 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 Contractor's . License Law. - ❑ I am exempt under Sec. , B & P C for this reason i 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 Workers 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 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. - icy arc. My Works Compensation Insurance c icr and Poll Came Policy No1AJ' •� r CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if the permit is for one hundred dollars (510(1) or less.) I certify that in the performance of the work for which this permit is issued, 1 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. 1 . I r CONSTRUCTION LENDING AGENCY � I hereby affirm That there is a construction Icndirig 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 I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordinances and slate laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioned property for inspection purposes. ' r (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 ' t �� in consequence of the granting of [his permit. APPLIC NT UNDERSTAN S AND WI CO Y WITH ALL NON -POINT SOUR RE,G,U,LAN9 , Issued by: - Date �L' f� '- Re -roofs Roof f igifam& of ApplicanUContractor Date - HAZARDOUS MATERIALS DISCLOSURE Type Of 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 credo, Section 25532(a)?All roofs shall be inspected prior t0 any roofing material being installed. ❑Yes No 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 Area Air Quality Management all new materials for inspection. District? - ❑ Yes ❑ u I have read the hazardous materials requirements under Chaptcr 6.95 of thc Califor- alifor-niaHealth&SafetyCode, nia Health & Safety Code,Sections 25505,25533 and 25534.l'understandthat ifthe building ' does not t rently have a tenant, that i is my resonsibility to notify the occupant of the ' trcmcnc su mu o iss :.Per aCertificate Occupancy. Mott Signature of Applicant Date .• ,-.�� ,S�'ij7 �� All roof coverings to be Class "B" or better '��-��7/ -authorized Owner or agetnt Date