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07070058BUILDING DIVISION PERMIT M955sSTEVENS CREEK BLVD OWNER'S NAME: SAND HILL PROPERTY CO ARCHITECT/ENGINEER: 1 o ZO LICENSED CONTRACTOR'S DECLARATION i U 1 fib' affirm that I am licensed under provisions of Chapter 9 (commencing 7�. with Section 70D0) of Division 3 of the Business and Professions Code, and my license is ra„ in full force and effect. ) rg z License Class Lac. 0 F„ q Date Contractor 7W ARCHITECTS DECLARATION j < I understand my plans shall be used as public records >yU Y. t; Licensed Professional O S OWNER-BUlDLA ER DECLARATION I hereby ..T... that 1 am exempt from the Contractors License law for the 20 following reason. (Section 7031.5. Business and Professions Code. Any city or county `e - f,4 which requires a permit to construct, alter. improve, demolish, or repair any struetam Z y 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 F $ (commencing with Section 70D0) 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 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (SSOD). ❑ 1, as owner of the property, or my employees 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, tie 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 (Sex. 7044. Business and Professions Code.) The Contracmes 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 Contractors Limtse law. ❑ 1 am exempt under Sex. . B & P C for this reason PERMIT NO. MIDSTATE CONSTRUCTION 1 07070058 1180 HOLM RD (707) 762-3200 PERMIT ISSUE DATE SANITARY NO. CONTROL NO. BUILDING PERMIT INFO ELECT PLUMB MECH Job Description REVISION -SHELL SCOPE OF WORK CHANGED. ORIG PERMIT #06090044-NO NEW PERMIT. FEES 261.42 PD ON ORIG PERMIT IN ERROR.BS000001891. Sq. Ft. Floor Area 32631020pi8W 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 WorkeesCompen- 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 Insuranceas required by Section 3700 of the Labor Code, for the performance of the worst for which this permit is ironed. My Workers Compensation Insuramx carrier and Policy number arc: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if lbe permit is for one hundred dollars(SI00) or less) I certify, that in the performance of the work for which this permit is issued, I shall mot employ any person in any manner so as to become subject to the Workers' Compensation Laws of California. Due Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you mint Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY [--i ram+ 1 hereby affirm slut there is a construction lending agency for the performance of GY, > the work for which this permit is issued (Sec. 3097, Civ. C.) Q Lenders Name a Z Lenders Address U O I certify that I have read this application and state that the above information is Vr correct. 1 agree to comply with all city and county ordinances and state laws relating to U U building construction, and hereby authorize representatives of this city to enter upon the U above -mentioned properly for inspection purposes. C1. (We) agree to save, indemnify and keep harmless the City of Cupertino against rA liabilities, judgments, costs and expenses which may in any way accuc against said City U Z in consequence of the granting of this permit. ►�' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: SOURCE REGULATIONS. Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hi ardous malarial as defined by the Cupertino Municipal Code. Chapter 9.1t and the Health and Safay Code, Section 25532(a)? ❑Yes ❑No 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 District? ❑ Yes ❑ No l have read the hazardous materials requirements under Chapter 6.95 of tie Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the bolding does not currently haws a tenant, that it is my responsibility to notify the occupam of the requirements which must be met prior to issuance of a Ccrtirwm of Occupancy. Re -roofs Type of Roof $0 Required Inspections ara Date on Type 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 Owner or authorized agent Date z� CO W�A, >D UC L>~ E O [ Fr r-r G U: r CITY OF CUPERTINO f t'°` BUILDING DIVISION PERMIT�� BUILD RESS: D�5 PERMIT . ��STEVENS CREEK BLVD MIDSTATE CONSTRUCTION 06 0044 OWNER'S NAME: MITISSUE DAZE SAND HILL PROPERTY CO 1180 HOLM RD PHONE: SANITARY NO. CONTROL NO. (707) 762-3200 ARCHITECTIENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section 7000 of Division 3 of the Business and Profiessions Code, and my license is TI-GROCERY STORE IN AN (E) SHELL BUILDING in full fora and affect License class Lic.» INCLUDES: MECHANICAL,ELECTRICAL,PLUMBING, ETC. Date ConARCHITECTS D CLARATION REVISION 0 7 0 3 014 8, 0 7 0 7 0 0 5 8, 0 7 0 7 016 7 I understand my plans shall he 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 to its issuance, also requires the applicant for such permit to file a signed statmoent the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation that he Is licensed pursuant to the provisions or (commencing with Section 70D0) of Division 3 of the Business and Professions Code)or $ 5 5 0 0 0 0 0 that he is exempt therefrom and the basis for the alleged exemption Any violad6a of 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 (5500)- 32631020 Las owner of the property, or my employees with wages as their sole compeasadon, Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Code The Contractors 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 sal, ID 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 rxntrrntxors to nstruct the project (Sex 7044, Business and Professions Code:) The Ccotraerors U cause 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 Contractors License Law. ❑ 1 am exempt under See , B & P C for this mum �s��� Owner Due ORKER'S CO SA N DECLARATION —'Q �5�l I hereby affirm under penalty of perjury one of the following declaration= 1 hs+e and will maintain a Certificate of Consent to self-hsum for Workers Compen. O� 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 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 I My Workers Compensation Insurance carrier and Policy number are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is fun one hundred dollars ($100) or less.) I certify that in the performance of the work for which this permit is issued I shin not employ any person io an mann�Sa rlit�¢ecp®gsubjcct w the Worlars' Compensation Laws or caliro 3C 1� ] 1 I Applicant NOTICE TO APPLICANT: If, after making�us Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Cod, you must ' forthwith comply with such provisions or this permit shall be deemed revoked. ) . CONSTRucnON LENDING AGENCY 1 hereby affirm that there is a contt uctinn lending agency for the performance of ' the work for which this permit is issued (See. 3097. Civ. C.) Lender's Name " Lenders address 1 certify that I have read this application and state that the above information is 4 correct. 1 agree to comply with all city and county ordinances and state laws relating to y building construction. and hereby authorize representatives of this city to enter upon the ahove-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 • APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT ��,, /� � Issued by: Date U �:. LJ'� SOUR R ATIONS. ^ Re -roofs Type of.Roof c, 1 ► J Sig reofKpplicani/ConLractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12• and the Health and Safety Code, Section 25532(a)? Nm All roofs shall be inspected prior to any roofing material being installed. Yes 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 wbich emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? --/ ❑ Yes �O I have mad the hazardous materials requimmens under Chapter G95 of the Califor- nia Health & Safety Code. Sections 25505,25533 and 2553 4. 1 understand that if the building does n t cu have a tenant. that it is my responsibility to notify the occupant or the re me wn h must be met prior to issuance of a Certificate RI -� Signature of Applicant Date All roof coverings to be Class "B" or better Date Owner or authorized agent