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CITY OF CUPERTINO
BUILDING DIVISION PERMIT��,l11
A
BUILDING ADDRESS:
19620 STEVENS CREEK BLVD
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TBD — TO BE DETERMINED
PERMIT NO.
07060051
OWNER'S NAME:
PERIv TISSUE DATE
EVERSHINE VI LP
12/04/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions or Chapter 9 (commencing
With Section 7000) oCDivision 3 of the Business and Professions Code, ny license is
DEMO (E) COMMERCIAL BUILDING .
in full force and effect
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License Class Lic. ii
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt Crom 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 rile a signed statement
to Contractor's License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant the provisions of the (Chapter
$130000
(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
369060'10. Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofA�bi
not more than five hundred dollars (5500).
- U V
❑ I, 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 Contactors License Law does not apply to an owner of
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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
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's 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 to the Contractor's
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:
❑ 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 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued,
M Worker'snc nsation In ante cater and Poli number arc* Q
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Cam'er.���t'U
CERTIFICATE OF EXEMPTTON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ifthe permit is for one hundred dollars ($100)
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 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 Worker's Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
i the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I I certify that I have read this application and state that the above information is
Correct. eI 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.
agree los ,indemnify and keep harmless the City of Cupertino against
j liebi ' expenses which may in any way against said City
es, ju mcnts os nd accrue
in c nse ucn oC th gran g oC this permit.
A I UND ST AND WILL COMPLY WITH LL ON -POINT
Issued by: Date
S
O /
Re -roofs
Type Of Roof
S oat a orApplican C factor tDate
H ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore orhandle hazardous material
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as defined by the Cupertino Municip 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.
El Yes o•
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 d fined by the BayArca Air Quality Management
all new materials for inspection.
Districl7
❑Yes u
I have read the hazardous materials requirements rChapter 6.95 of ibe Califer-
niaHealth &SafetyCode, Sections 25505,25533 and I understand that ir [he building
does not currently have a tenant, that it is my ibility to notify the occupant of the
-mqus et prior to iss of a Certificate of Occ panty
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or authorized agent Dale -