08100111CITY OF CUPERTINO
BUILDING DIVISION
PERMIT
BUILDING ADDRESS:
20400 MARl
OWNER'S NAME:
CONiROLNO.
(408)271-2425
ARCHITECTIENGlNEER: BlJlLDlNG PERMrT INFO
BLDG ELECT PLUMB MECH
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~~ F; I bcn:by alIirm Ihll I am lI",nscd under provisions of Qlapu:r 9 (commencinc Job Description
~:ll wllh Section 7000) ofDivWon 3 wille Busi""'"and Professions Code•.and my license iJ ~::>e; infullfora:ande(fecL i r-.......<>-COMM' L TI EXTERIOR SITE WI< MOD FOR ACC'C'SSBL PATHSJ!:l i?i Ucense a... Lie. , _~Co""'"=....; ."..-y~uo,.,~_____ ;-_f-~ DII;--,i:1 , .... 1.,.,., ConlnCtDr..(L CO ..."'....".. OF TRVL& NEW BTHRM COREl STRCTRL WI< RLTTD TO INTER
-:l ~ , ARCHITEcrS DECLo\RATION ~~ -< I undcnland my plllU shall be used u public "",orda IMPRVMNET / STRUCTURAL INCLUDED
J~U
t u. ... Licensed Professional !lo'"OWNER·BUILDER DECLo\RATION~~j I hereby .mrm Ihal I am aempt frum IJ\c COnlnlClor's License Law for IJ\ci!-<:l -co following reason. (Section 7031.5. BusindS and Professions Code: Any cily or counly ~d which requires a permil to ~onsuuc~ a1u:r. impnl"". demullsh. or repair any stnIClure
ll-",prior to its issuance. also requires tbe applicant (or such pennillO lil.c: a JiCncd JLalCmcnl f-------;:;---;::::--;:::.-::-~._:_~------r-------___:,.".._:_-,...._---------_z >---< Ihal he iJ licensed pursuanllo IJ\c (II'Ovisions oflJ\c ConlnlCtor's Ucense Law (Chlpu:r9 ~~c (eommcncinc wilh Section 7000) at Division 3 of IJ\c Business and Prof""ions C~) or ~i~ ~hciJ=.~~andlllc~~IJ\c_~=_~~~~on~I
Section 703U by any applicant for a permllsubjcc" the appllcanllo a civil penally of r
DOl more lhan Ii"" hundred dolla,.. (s.500).
D I. u owner ofllie property. army C1'1Iploycc.s wllh WlIpulheiTsolecompenution. L
will do Ihe wart. and the II\nlClurc Is not inLendcd or oITem! (0.sale (Sec. 7044.Busi .... r
and Professions Code: The ConlllClor's Liee"'" Law does not apply", an owner of
propc:rly who buildl or improves thcrc<>n.and who doessueh wad'himself or lJIrough biJ
own emploY=. provided lhal such impro""mcn.. are nor. inlend~ or olTCRd for sale. II.
however. lhe buildinc or impro...."'t iJ sold wilhin one year or completion, dle owner-
builder will ha"" IJ\c bunlen of proving lbat he did not build or improve for pulJlOlC of
sale.).
D I.... owner or IJ\c propeny. am w:lusively eonlnlClinc wilh lia~ con1l1l:lOn 10
construCl the projeCl (Sec. 7044. Business aod Professions Code:) The ConlrJCtor's Li·
cense: Law does nOI apply 10 an owner of property wbo builds or improves ~n. and .
who conlnle" for such projeClS wilh I conll'lClons) li=d pursuant'" IJ\c ContrllCtor's
Ucense:Law.
D I am exempt under Sec. • B &. PC for lhiJ rei&SOll
Owner DaLe.~ _ ----::W';';O"'R:-::K;;:ER='S:-;C:;::OM=P;;EN=S-:An=O~N:-;D:;::EC=Lo\"7;;'RATION
I hereby alIirm under penally of peljury one of the followinc declarations:
D I h....nd will malnllin a CcniliaLeofConsenllo self-Insure forWorka's Campen
IIlion. u provided for by Section 3700 of lhe Labor Code. for IJ\c performance of lIlc
work for which lhiJ permit is iJsucd.
D I ha"" and will malnllin Wortr:r's Compc:nsation Insunncc. IS required by ~on
3100 of IJ\c Labor Code. forlJ\c performanccofthe wort ror which Ibis permlL is issued.
My WoritCf's Compensation ~camer and Policy n~.ber 'ft. d r 01 ()
Carrier: ~ltTyl'-~t.-Polley No.: -Li.,.O'--"'lLL-7-=-----=..)_' __
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ThiJ secllon need not be eompleLCd If lbc permit is ror one hundred don...(S 100)
or less.)
I ccnify 1h0i in <he performance of lbc work for which Ihis permit iJ issued. I shall not
employ any pe"on in any manner 50 IS 10 become subjecllo IJ\c Wortus' Compensation Laws of California. Da'" _
Applicanl_~-===:_:_:c_:-___,-.....,..c_::-=-....,..,::--.,__--:-.,.,
NOTICE 10 APPUCANT: If. afler makinc lhiJ Certitiea'" or Exemplion. you should
become SUbjcCl to lhe Wortet's Compensation provisions of the Labor Code. you mUSl
forthwilh comply wit.h such provisions or lhi.s pc~il shall be deemed n:vok.cd.
CONSlRUcnON LENDING AGENCY
I hereby alIirm Ihll there ls ~ consuuctinn lendinc agency for lbc performance of
IJ\c work for which lhi> permit is issued (Scc. 3091. Ciy. C)Lender's Name: _
Lender'sAddrcss _
I certify lhal I ha"" read !hi. appliealion and SUl'" lhlllJ\c abo"" informatiun iJ
correct. 1ac= to comply wilh all o,y and counlY onJinanczs and SUlle I.,.. relatinc to
buildinc construction, JJ'ld hc:n:by aulhOri7J: n::prescnLauycs of this cily to enter u.pon the
above-mentioned propeny for inspection purposes.
. (We) agree 10 sa"", indemnify and I:top harmless IJ\c Cily of Cupertino acalnsl
liabilitic.J, Judcmcn ... costs and ..pe...,. which may in any way accrue acalns! said Cily
in consequence or the cranting or litis permiL
APPLI S AND WILL COMPLY WITH ALL
SO CE 1
Will Ote applicant or (uture buH . g occupant usc equipment or devices which
emil hazardous air conLlminants as ned by the Bay Area Air Quality Management
Sq. Ft. Floor Area Valuation
~~~~=C~-------~-~~7~5wO~O~O~O~O~ _____:=-------_APN Number Occupancy Type
31622018.00 --:::-_--:-_-:-::L__-:_
Required Inspections
Issued by: Date
Re-roofs
Type of Roof
AIl roofs shaIl 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.
DisU'ic11
DYes
Signature of Applicant Date
All roof coverings to be Class ''J1.j or better•