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BUILDING DIVISION PERNUT
S S.:
BUILDING ADDRESS:
PERMIT NO.
19333 VALLCO PARKWAY BLDG B
DPR CON TR TI
OWNER'S NAME:
PERbIIT ISSUE DATE
PHONE:
S A CONTROL NO.
(650)474-1450
ARCHITECT/ENGINEER:
BUILDING PERMrrINFO
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 Codc. and my license is
in full force andeffecL C�
s Rs q 6
TEMPORARY PERMIT FOR BLDG B SEISMIC STRUCTL
.
License Class Lie If r
Date Contractor
UPGRADES ORIG #09060065—PERMIT GOOD FOR 30 DAYS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
TILL 8 / 9 / 0 9 . NO FINALS ON THIS PERMIT.
Licensed Professional'
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's 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 statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
that he Is exempt therefrom and the basis for the alleged exemption, Any violation of
5 0 0 0 0 0
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 (5500).
31620075.BLDGB
❑ L asowner of the property, or my employes withwages astheir We compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Profession Code: The Contractors License Law dots 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 We. If.
however, the building or improvement is sold within one year of compfeden, the owner -
builder will have the burden of proving that he did sit build or improve for purpose of
salt.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Profession code:) The Contractors U.
cease 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 Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hive and w81 maintain aCertificate 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.
❑ 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 Workers Compensation Insurance carrier and Policy number are:
Cartier: 1i11W S A)Ii l Policy No.:
CERTIFICATE OF EXEMPTION FROM WOR M&
COMPENSATION INSURANCE
(rhh section need riot be completed If the permit is for one hundred dollars ($100)
or lest)
1 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 Worken' Compensation
Laws of California Date
Applcant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provision of the Labor Codc, you must
forthwith comply with such provision or this permit shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
1 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 Namc
Lender's Address
I 1 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 state laws relating to
building construction, and hereby authorim 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
j liabilities, judgments,cosu and expenses which may in any way accrue against said City
in consequence of the granting of this permlL
APPLICANT UNDERSTANDS AND WILL COMPLY WLTH ALL NON -POINT
�
Issued by: Date
SOURCERE S.
Re -roofs
Type of Roof
1.2--CAL 1-MO
Signature of(ApplicantConLractor Da
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building occupant store or handle hazardons 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 Mamgcmcni
all new materials for inspection.
District? /�
❑Yes W No
1 have read the hazardous materials requirements undcrChapW 6.95 of the Califor-
nia Health & Safety Code, Section 25505.25533 and 25534.1 understand that if the building
dexs not currently have a tenant that It is my responsibility to notify the occupant of the
mgahcm h must be mct prior w issuance ofa Certificate of Occupancy.
Signature of Applicant Date
`�� � �'� 7/C)9
All roof coverings to be Class 'A" or better
Owner ox thorin agent Date