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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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STEVENSTEVENS CREEK BLVD
SAN JOSE CONSTRUCTION
08080180
OWNER'S NAME:
PERMIT ISSUE DATE
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SANITARY NO. CONTROL NO.
(408)986-8711
ARCHriECUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivision 3 ofthe Business and Professions Code, and my license is
REVISION: REVISE FIRE RATED WALL TO CEILING
in full force and effect
License Class Lic. t
DETAIL
Date ARCHITEMDEECCLARATION
ORIGINAL PERMIT 07060128—NO NEW PERMIT.
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, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Conuactoes License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
7000) Division 3 Business Professions Code) or
$ 9 5 0 0
(commencing with Section of of the and
that he is exempt therefrom and the basis for the alleged exemption Any violation of
3 6906010 Number
Occupancy
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dell= (5500).
.
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❑ L, as owner of the property, or my employees 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 Conuactor's License Law does 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 sale. 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
sa1eJ.
as owner of the property, am exclusively contracting with licensed contractors to
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nswct the project (Sec. 7044. Business and Professions Code:) The Contractor's U-
cease Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a conlractor(s) licensed pursuant to the Conuactot's
License Law.
❑ I am exaoQpt under Sec . B & P C(�for this mason
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W RKEWS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of The following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workcts 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 Workees Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be canplcied if the permit is for one hundred dollars (S I00)
or less)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any m qr Fo asp beck subjccl to the Workers' Compensation
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Laws of Califon Date. f G
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Applicant
NOTICE TO APPLICANT: If, after making this Certificate 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 he deemed revoked.
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' CONSTRUCTION LENDING AGENCY
i 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.)
Leender's Name
Lender's Address
I certify that I have read 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
j 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 WrTH ALL NON -POINT
Issued by: Date Z
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SOURCE GULATI S. (� J 2L I }j
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Re -roofs
'Type Of ROOF
Signature ofApplican ntractor Date
HAZARDOUS MATERIALS DISCLOSURE,
WIII the applicant or future building 0=pant 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
All roofs shall be inspected prior to any roofing material being installed.
❑Yes MNo
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 '[] No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant. that it is my responsibilily to notify the occupant of the
requircmGt,ts whic}ymust be met prior to issuance of a CcNGcatc of lccupanry.
Signature of Applicant Date
All roof coverings to be Class 'A" or better
Date
owner Farm edag,