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080100630C Z C r/ z� ii7 � UC Il~ F C) C (~ G OF CITY OF CUPERTINO BUILDING DIVISION PERNUT �k� MM Mo BUILDING ADDRESS: PERMrT NO. 20041 BOLLINGER RD TBD - TO BE DETERMINED 08010063 OWNER'S NAME: PERh4T LSSUE DATE PACIFIC RIM PK LLC 08/11/2008 PHONE SANITARY NO. CONTROL NO. ARCHITEC (ENGINEER: BUr SING PERMIT INFO BLDG ELECT PLUMB MECH o © o 0 LICENSED CONTRACTOR'S DECLARATION Job Description 1 herchy affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) ofDivision 3 ofthc Business and Professions Code, ad my license is LOCATE A CELL SITE WITHIN THE RIGHT OF WAY in tali fora and effect 7�gg�S Lian�C�t Lie # REPLACING AN EXISTING LIGHT STANDARD WITH ARCHITECTSMCI toECLARATION SSOCIATED EQUIPMENT BEHIND AN EXISTING BUILDING. I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I 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, aher. improve, demolish, or repair any sWcture prior to is issuance, also requires the applicant for such permit to file a signed.statema i he is licensed to the the Contractor's Uccnsc Law (Chapter 9 Sq. Ft. Floor Area Valuation that pursuant provisions of 7 5 00 0 (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 y Number ' Occupancy Type Section 7031s by any applicant for a permit subjects the applicant to acivil penalty of am mom than five hundred dollars (MWo 36934052. CT2 ❑ L as owner of the property. or my employees with wages as their sole compensation, Required Inspections will do the work and the struclme Is not intended or offered for sale (Sec.7044, Business and Professions Code. The Contractors License Law does not apply to an owner of q P property who builds or improves thereon, and who does such work himself or through his own employers, provided that such Improvements are not intended oroffered fur sale. If. however, the building or improvement is sold within one year of completion, die owner - builder will have the burden of proving that he did not build or Improve for purpose of sale.). ❑ L as owner of the property, am exclusively contracting with licensed contractors to construct 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 contractor(s) licensed pursuant Lo cite Conuacrors License Law. ❑ 1 am exempt under Sec. , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations ❑ I ha ve and will maintain a Certificate of Consent to self-insum 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 Workr:ra ore�'per/tas�.on lns=na artier and Policy number am: Cartier. /z «'�f- Policy Na: y�P ����L CF_R ISCATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE ((his section need not be completed If the permit Is for one hundred Collars (S )OM . or less.) I cer)fv that In the performance of the work for which this permit is issued. 1 shall not employ any person in any manner so as to become subject to the Workers' Compensation _ Laws of California. Date 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 mew forthwith comply with such provisions or this permit shall be deemed nvokcd i 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 Name , Lender's Address I I certify that I have read this application and auto that the•abow information Is correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorise representatives of this city to enter upon the above -mentioned property for inspection purposes. � (We) spec to save, indemnify and keep harmless the City of Cupertino against "kw liabilities, jodgmems, toss and expenses which may In any way scenic against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date �S L CE REGULATIONS. Re -roofs Type of Roof h<x496t��^ Sn atureofAppliant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant atom or handle haardaas mammal as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, section 25532(a)? ❑Yes XNo 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 Will the applicant or fuL= building occupant use equipment or devices which emit hazardous air consminans as defined by the Bay Arta Air Quality Management all new materials for inspection. District? ❑ Yes ]No I have read the hazardous maws ials requirements under Chapter 6.95 of cite Califor- nia Hcal Lh & Safely Code. Sections 25505, 25533 and 2 534.1 undcrsrand Lhat If the building does not currently have a tenant. that it is my responsibility to notify the occuparn of the regQbt7to which must be met prior to issuance of certificate of Occupancy/ ,� 5 Signature of Applicant Date , hQs� `°p9� tt� All roof coverings to be Class 'A' or better 01 or authornZd agent ate