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CITY OF CUPERTINO �zI�,��7�+
DIVISION PERMIT
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BUILDING
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Bulifl8bTgRE8RANGE AVE BLDG C
TBD — TO BE DETERMINED
PERMIT NO.
08030161
OWNER'S NAME:
PERMIT ISSUE DATE
MARCI PROPERTIES LLC
09/05/2008
PHONE:
SANITARY NO. CONTROL NO,
ARcHrrvCT/ENGiNEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter (commencing
with Section 70M ofDivWon 3 ofthc Business and Proflessions; Code, ad my Ikense is
SFDWL 2 STORY 1,814 SQFT—BLDG C MULTI —USE
in full force and effect
uceaacClass Lic.#
8/6 ADDED 2 HRS SUPPL PLAN CHECK FEE.
Dale _ Contractor
- -
ARCHITECTS DECLARATION
I understand my plans shill be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031:5, Business and Professions Cade: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to rile a signed statement
licensed to the the Contractors license Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is pursuant provisions of
$ 2 3 5 8 2 0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt thorefrom and the bass for the alleged exemption. Any violation of
�,p� umber
3 5 717 0 5 8
OCCllanC
Occupancy Type
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (ssoo).
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❑ 1, as owner of the property, or my employes with wages as their sole compensation,
.
Required Inspections
will do the work, and the structure IS not intended or offered for sale (Sec 7044. Business
and Professions Code: The Contractor: License Law does not apply to an owner of
property who builds or improves thereon. and who does suchwork himself or through his
own employees, pmAdcd that such improvements are not intended or offered for sale. if.
however, the building or improvement is sold within ore year of completion, the owner-
buikier will have the burden of proving Thal he did not build or improve for purpose of
salej.
Kas owner of the property, am exclusively conuseting with licensed contractors to
.Lrvet the project (Sec 7044. Business and Professions Code:) The Contractors Li-
ccrtse Law does not apply to an owner of property who builds or Improves thereon, and,
who contracts for such projects with a contractors) licensed pursuant to the Contractors
TIC. Law- .
❑ I am ex t antler B& P C for Ibis m4son
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Owns
�'—WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of per ju y one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Insure for Worker's 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 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 am:
Carrier. Policy No.:
CERTIFICATE OF E XEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is forore hundred dollars ($100)
or Icss)
I certify that in the performance of the work rot which this permit is issued 1 shall not
employ any person in any manncr6p a�io�,bcco�c, uhieet to the Workers' Compensation
Laws of 1
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Applicant /; /�/41
NOTICE Li : i , after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code. you mum
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
i 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 Namc
,
Lender's Address
I terrify that I have card this application and state that the above information is
correct I agree to comply with all City and county ordinances and state laws relating to
building construction, and hereby authorize 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
liabilities, judgments costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLI UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
CE ULAITON � /�� r1
Re -roofs
Type of Roof
Signature of ApplianVCpYasW Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous malarial
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes 0No
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
WIII the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Ara Air Quality Management
all new materials for inspection.
Diauict7
�'No
❑ Yes
I have read the hazardous materials requirements under Chapter 6.95 of Ibe Ca)ifor-
nia Health & Safety Code. Sections 25505, 25533 and 25534,1 understand that iithe building
does not currently have a taunt that it is my responsibility to notify the occupant of the
requertri°
ef5l�tl
Signature ofApplicant Date7/
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