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CITY OF CUPERTINO
PERMITY,±y�R
F
BUILDING DIVISION
Bu1LQI[jG.,^pf),R ORANGE AVE BLDG A
E(J(NJAjME--
TBD — TO BE DETERMINED
8030160
OWNERS
PERMIT LSSUE DATE
MARCI PROPERTIES LLC
09/05/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHnT=/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I licensed Chapter 9
Job Description
I hereby affirm that are under provision of (commencing
with Section 70D0)of Division 3 ofthe Business and ProfessionsCodc,aW my license is
SFDWL 1, 283 n IN MIXED USE BUILDING. BLDG A RESID.
in full force and effecL
License Class - Lk. N
Date Contractor
-
ARCHrrECPS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70313, 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
drat he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
16 6 7 9 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 5 717 0 5 8 `P Number
Occupancy
Pane Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a CNN penalty of
not more than five hundred dollars (SYM
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the worir, and the stmetmr is not intended oroffered for sale (s«.7044,Business
and Professions Code: The ContractorLicense Law does not apply to an owner of
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property who builds or im proves thereon, and who does such work himselfor through his
own employees, provided that =h improvemerus are not Intended or offered for nit 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 a,improve for purpose of
sale.).
I, as owner of the property, am exclusively contracting with licensed contractors to
nstruct the project (Sec. 7044, Business and Professions Code) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves Thereon, and
who contracts for such projects with a contnctor(s) licensed pursuant to the Contractor's
License Law.
❑ I am t under Sec B & P C for this reason
Owner Date r-O
WORKERS MPENSATTON DECLARA17ON
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 Compm-
sation, as provided for by Section 37D0 of the Labor Code, for the perform&= 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.
My Workers Compensation Insurance carrier and Policy number am:
-
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ibis section necd not be completed it the permit is for one hundred dollars ($100)
or ICU)
I certify that in the performance of the work f r which this permit is issued. I shall not
employ any person in any mane dab cyst bjecl to the Wortrn' Compensation
Laws of Califop "4 Date U
Applicant ii'Y7 x,
NOTICE TO AV011CAW. If, after making this Certificae 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.
—
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.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
corrccL I agree to comply with all city and county ordimrrces and state laws relating to
building construction, and hereby auihorire representatives of this city to enter upon the
above-mendoned 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
S CE RFG LA770NS.
8
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Sr
Re -roofs
Type of Roof
Signature of Applicant/2traYasdFh ale
HAZARDOUS MATERIALS DISCLOSURE
Wln the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Codc, Chapter 9.12. and the Health and Safety
Code,Section 25532(a)7
❑ YesAll
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
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 o
I have read the hazardous marcrials requirements under Chapter 6.95 of the Cahlbr-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand dui if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
rats which m be mpet�Pnor two mats"" of a Certificate ofGOcc/7�
Signature of Applicant Date
Owner or suthorired agent 6aLc till IUU1 CUVCf1Ilgb LU Ur, l..Idsb _tt Uf ucuelt