08120128BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19620 STEVENS C
OWNER'S NAME:
ARCHI ECTIENGINEER
Z O Zp LICENSED CONTRACTOR'S DECLARATION
turf 1 hereby affirm that I am rimmed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the BuAnev and Professions Code, and my license is
H in full force and effort
Z License Class Lie. r
i O Date Contractor
e ARCHITECTS DECLARATION
rt I understand my plans &hall be used as public records
rm t; Licensed Professional
J OWNER -BUILDER DECLARATION
J�1 hereby affirm that 1 am exempt from the Contractors LIcc= Law for the
<p O following reason. (Section 7031.5, Business and Professions Code: Any city or county
m which requires a permit to construct. after, improve, demolish, or nrytair any Structure
u `~ prior to its issuance, also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the previsions of the Contractors license Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that be In exempt therefrom and the basis for the alleged exemption. Any violation of
Season 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five 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 sae (Sec. 7044, Business
and Professions Code The Contractors Liaise 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 be did not build or improve for purpose of
sae L
fA I. as owner of the property. am exclusively contracting with licensed contractors to
comtroct the project (See. 7044. Business and Professions Code:) The Contractors U-
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) Bcemd pursuant to the Contractors
Ucenae Law.
❑ I am exert und7See B & P C for this reason
Owner - Date 3113 / a
'rT3GOltKFJiS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificata of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3100 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhu section need not be completed if the permit is for one hundred dollars ($100)
or has)
I exnify that In the performance of the work for which this permit is Issued. 1 shall not
employ any person In an manner so as to become subject to the Worker! Compensation
ems of CAT!a. DNb
Applicant A
NOTICE T0_KPIfLA6kNT. IL after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
,J O forthwith comply with such provisions or this petmil shall be dcrnmcd revoked.
z CONSTRUCnON LENDING AGENCY
[~'n h�-r I hereby affirm that there is a construction lending agency for the performance of
(Y 7 the work for which this permit is issued (Sec. 3097, Civ. C.)
WlL Q Lender's Name
L z Lenders Address
V O I anify that I have read this application and state that the above information is
(y correct. I agree to comply with all city and county ordinances and state laws Misting e
SV" building construction, and hereby authorize mprasentadves of this city to enter upon the
IIa above -mentioned property for inspection purposes.
Or (Wo) agree to saw, indemnify and keep harmless the City of Cupertino against
rA liabilities, judgments, toss and expenses which may in any way acme against said City
U Z in consequence of the granting of this permit.
h r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RpGULA'i70NS. 3 )1 3 1 b l
si urc4 =l UContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hrordous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section 25532(a)?
❑ Yes Evo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the flay Area Air Quality Management
District?
Q Yes We
I have read the hazardous materials mquim=nts underChapfer 6.95 of the Califor-
nia Health & Safay Code, Satins 25505, 25533 and 25534.1 ur4cmand that if the bwlcing
does not have a tenant. that It is my responsibility to notify the Occupant of the
req i me y must be met prior to issuance Of a certificate of Occupancy. I
Owner or authorized aecnl Date
PEKMFF NO.
DETERMINED 0812C
PERMrr ISSUE DATE
SXWA2CONTROL NO.
BUILDING PERMIT INPO
BLDC ELECT PLUMB MECH
Job Description
20 FANCOIL UNITS & 20 HEAT PUMPS INSTALLED
3/2/9 - RE -FUND $1346.19 ON CREDIT CARD, CHNGD
APPLICATION FROM 40 TO 28 UNIT & ADDED
Floor Area
36906010.00
Issued by:
Re -roofs
Type of Roof
150000
Required Inspections
Valuation
Occupancy Type
Date —3-- /S
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'n"' or better