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CITE' OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT
BUILDING ADDRESS:
19620 STEVENS CREEK BLVD
SAN JOSE CONSTRUCTION
PERMIT NO.
08040089
OWNER'S NAME:
FERMIT ISSUE DATE
EVERSHINE VI LP
1210 COLEMAN AVE
05/23/2008
PHONE:
SANITARY NO. CONTROL NO. .
(408)986-8711
ARCHITECTfENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70(10) orDivision 3 of the Business and Professions Code, and my license is
REV I S I ON— GREAT LINE MODI F I CATION ( P
in full force anLicense Class d effect Lic, #
2 . 1) ORIG# 0 7 0 6 012 8 NO NEW PERMIT.
Dale Contractor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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 conswct, alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant Cor such permit to rile a signed statement
Law 9
that he is licensed pursuanito the provisions of the Contractor's License (Chapter
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(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
�j Number
3 6 9 0 6 0 1 0 .,V '
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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will do the work, and the structure isnotintendedoroffered for sale (Sec.7044,Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended arof[ered 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
Sal
I, as owner of the properly, 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 contraclor(s) licensed pursuant to the Contractor's
License Law.
0 1 am exey unrr 5., , B & P C for -this reason
Ow er Llu9� Date C Z 0
_
RK 'S MFENSATIONDECLARATION
I hereby affirm under, ;Ity 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 Code, for the performance of the
work for which this permit is issued.
M 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.
My Workers Compensation Insurance carrier and Policy number are:
-
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(This section need notbe completed if the permit is forone 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 manger tp o 59 c subject to the Workers' Compensation
Laws or Calif & Ito
Applicant
NOTICE T AP LIC&M if, after aking this Certificate of Exemption, you should
become subject to the Worker's Com nsstion provisions of the Labor Code, you must
-
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consuuctinn lending agency rar the performance of
,
~ the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
D 1 certify that I have read this application and state that the above information is
comeet. I agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City or Cupertino against
e) liabilities, judgments, costs and expenses which may in anyway accrue against said City
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in consequence of the granting of this permit.
^i APPLICANT UNDEI0TA S AND WILL COMPLY WITH ALL NON -POINT
Issued by: Data
U_ EGU ONS.
At
Re -roofs
Type of Roof
igneC of pli ant(C n c! r
HAZARD�US MATERIALS DISCLOSURE Date
Will the applicant or future building occupant store or handle hazardous material
as derrned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
cede, Section 25532(a)? t/
All roofs shall be inspected prior to any roofing material being installed,
E] Yes (rte. "No
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? ^
❑Peso
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that if the building
does not rrend aon 'aye a tenat it is my responsibility to notify the occupant of the
requ c whi h m st be age p 'crus issuance of a Certificate of Occup , ey.
Signature of Applicant Date
� y , �. I
All roof coverings to be Class';f `' or better
Ownera aulho ized agent r1 Date