09010082BUILDING DIVISION PERART
BUILDING ADDRESS:
10100 N
OWNER'S NAME:
ARCHITEC IENGINEF.R:
O o LICENSED CONTRACTOR'S DECLARATION
u I bemby affirm that I am licensed under previsions of Chapter 9 (commencing
with Section 70D0) of Division 3 of Ibe Business and Professions Code, and my license is
H in full force and effect.
License Class I.ic. 0
qqq Date Contract r
CH
7F ARI =- DECLARA7ON
1 understand my plans shall be used as public records
3yU
# W Licensed Professional
0 OWNER -BUILDER DECLARA71ON
I hereby affirm that 1 am exempt from the Contractors License Law for the
00 following mason. (Section 7031.5, Busincs 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 rile a signed statement
< that he Is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil prmity of
not mom than rive hundred dollars (S500).
❑ L 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 Conusciors License Law does not apply to an owner of
property who builds or improKi thereon. and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sate. 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.).
ka L as owner of the property, am exclusively contracting with licensed contractors to
the project (Sec 7044. Business and Professions Code:) The Contractors LI-
ccase 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.
❑ I am exem ;3ee B & P C fothis
Ow� Due
/WC Pr SATON n
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 Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
weak for which this permit Is Issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Codc for the performance of the weak for which this permit is ivuhed
My Worker's Compensation Insurance artier and Policy number am:
Cartier: Policy No -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars ($I00)
or less.)
I certify that In the performance of IM work for whichAis permit Is Issued. 1 shell not
employ any pbrson In any mynelsoArOlbecomo Icct o the Worker' Compensation
Laws of Californi D
Applicant
NOTICE TO APPLICANT: m 'ng this 'Cam of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
7 CONSTRUCTION LENDING AGENCY
I-, I hereby afrum that there is a construction lending agency for the performance of
C4 the work for which this permit is issued (Sec. 3097, Civ. C)
W 0 Landres Name
Z Lenders Address
U Q I certify that I have read this application and state that the above information is
LL �" correct. 1 agree to comply with all city and county ordinances and state laws relating to
C) p , building construction, and hemby authorize representatives of this city to enter upon to
OWr above-montioned property for inspection purposes
(We) agme to save, indemnify and keep harmless the City of Cupertino against
W2 liabilities, judgments, costs and expenses which may in anyway active against said City
V 7 in conseque gsantng u it.
h� APPLIC �1L4 STA S AND WILL COMPLY WITH ALL NON- INT
SO GUI.
Signature of Applican n
HAZARDOUS MATERIALS DISCLOSURE
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(a)7
❑ Yes
Will do applicant o arum building occupant use equipment or devices which
emit hrrarlous air con nanis as defined by the Bay Area Air Quality Management
DLwict7
❑ Yes o
I have read the materials mqui ements under Chapter 6.95 of the Califor-
nia Health & Safety ohs 25505, and 25534.1 understand this if the building
does not curtent my responsibility to noufy the t of the
requimmenu to issuance of a Certificate of
/ O
Owner or authorized aecnl Date
408)255-9994
PERMIT NO.
PERMIT ISSUE DATE
Job Description
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
COMM'L TI INCLD HNDCAPD ACCESSBLTY UPGRDES,NEW
HVAC, NEW RF(50SQ),NEW STAIRS, SEISMIC UPGRD&
NEW
FIRE SPRNGLS= 4893SQ
Sq.
32631019.00
Issued by:
Re -roofs
Type of Roof
Area
Required Inspections
Valuation
Occupancy
Date 7't 'cal
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 'A" or better