06030074CITY OF CUPERTI.
BUILDING DIVISION
F.
BUILDING ADDRESS:
10123 N WOLFE RD
OWNER'S NAME:
LANDMARK PROPERTIES MGMT
PHONE:
ARCHrIECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700(1) of Division 3 of the Business and Professions Code, and my license is
in full force and effect 1' 01
License Class Lk. a (U /TJU
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Pnrfcssional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors 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 srntcture
prior to is issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (SSM.
❑ 1, 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 sale (Sec. 7044, Business
and Professions Code: The Conuwwr's Licensees Law donot apply toan owner of
property who builds or improves tercon, and who does such work himself or through his
own employees, provided that such improvements art: 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
sale.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
conswct the project (Sec 7044. Business and Professions Code:) The Contractors Li -
cc= Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a eonaactor(a) licensed pursuant to the Contractors
License Law.
❑ I 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
❑ 1 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 Coda for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insumon, as required by Section
3700 of the Labor Code. for the performance of the work for which this permit is issued
My Worker' 0�m{p�ens/citron. Insurance uarti d Policy number am:
Carrier: // r C9® gyrohliry No.:
CERTIFICATE OF EXEMPTION FitOM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or lee)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compesation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject in the Workers Compensation provisions of the Labor Coda 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.)
Lender's Name
Lender's Address
1 certify that 1 have mad this application and state that above information is
correct. 1 agree to comply with all city and county onli state laws relating to
building construction, and hereby authorize representa of is city to enter upnn the
about -mentioned property for inspection p rposes
(We) agree to save. indemnify keep h 1 c City of Cupertino against
liabilities, judgments. costs and ex which y i ` y way accrue against sai City
in consequence of the granting it. %
SOURCE REGULA' O/N APPLICANT D MPLY WITH NO`/fo
of
Date
Will de appUeant or futur*Widing occupant store or ham haardous material
as defined by the Cupertino Municipal Code. Chapter 9.1Z an Health and Safety
Code, Section 25532(a)?
❑Yes ❑No
Will the applicant or future building oric pant equipment or devices which
emit hazardous air contaminants as defined by de Bay Air Quality Management
District?
❑Yes ONO j
I have read the hazardous
nia Health & Safety Code, Seetoc
does not currently have a
mqu.=mcns which must be v
f�afu' sundcrChapter6.95 (thcCali(
d 25534.1 undcrst utd th f the but ag
onsibilft w notify occupan f the
of a Ccri fca c of ancr
TRUCTI ON INC '"I' I PERMrf N00 6 0 3 0 0 7 4
PERMIT ISSUE DATE
1450 VET
SANITARY NO, CONTROL NO.
(650)474-1450
Job Description
GAS METER ROOM
Sq. Ft. Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
BUILDING PERMIT INFO
ELECT PLUMB
200000
Valuation
Occupancy
Date J:7- 3- eC
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 "B" or better
Owner or authorized