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08100194CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: OWNER'S NAME: ARCHITECTIENGINEER: 1400 LICENSED CONTRACTOR'S DECLARATION V r I hereby affirm that I am licensed under provisions of Chapter 9 (commencing z W with Section 70fo) ofDivision 3 of the Business and Professions Code, and my license is a y in full force and effect. j Z License Class Lie. p 3 M p Date Contractor L ARCHITECTS DECLARATION # 1 understand my plans shall be used as public records a a ti Licensed Professional y OWNER -BUILDER DECLARATION a I hereby affirm that 1 am exempt from the Contractors License Law for the C O o following mason. (Section 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure Z prior to its issuance, also requires the applicant for such permit to file a signed statement x 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 y that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by arty applicant for a pencil subjects the applicant to a civil penally of not more than five hundred dollars ($500). ❑ 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 Contractor'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 sale.). 0-1, 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. ❑ lam exem undeyy Sec. B & P C for this reason Owner Date m 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. ❑ 1 have and will maintain Workces Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: Job Description REVISION—OCC TYPE, REV,EXT WALL, 2ND FLR CEILNG& COLLI RATNG;ORIG #07060035,#08030071—FIRE/PLNG CONDITIONS ON PLANS. Ft, Floor Area 36906010.00 Required Inspections Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is forone hundred dollar( ($100) or less.) 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person . any ma ne ;o ��come subject to the Workers' Compensation Laws of Caliform ale L° Applicant ' NOTICE TO A LICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY (~i iii I hereby affirm that there is a construction lending agency for the performance of CG r7 the work for which this permit Is issued (Sec. 3097, Civ. C.) a4A Lenders Name 0Z Lenders Address U 0 I certify that I have read this application and state that the above information is VL rr correct. I agree to comply with all city and county ordinances and slate laws relating to 0 V building conswction, and hereby authorize representatives of this city to enter upon the >.( aabove-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against .Hy to liabilities, judgments, costs and expenses which may in any way accrue against said City U '7 in consequence of the granting of this permit A APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: SOURCE REGULAq'IONS. I , Signature of ApplicanVContraclor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore or handle hazardous material as defined by the Cupertino Munidipal Code, Chapter 9.12, and the Health and Safely Code, Section 25532(a)? ❑Yes (No 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 District? ❑ Yes '.No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Hcalth & Safety Codc, Secdons 25505, 25533 and 25534.1 understand that If the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requi, encs * h must be mel prior to issuance of a Certificate of upancy. ilc Io Owner or authorized agent Date Re -roofs Type of Roof Type Date /� /__ 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'" or better PERMIT NO. PERMIT ISSUE DATE RLC� E)08 CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB - MECH Job Description REVISION—OCC TYPE, REV,EXT WALL, 2ND FLR CEILNG& COLLI RATNG;ORIG #07060035,#08030071—FIRE/PLNG CONDITIONS ON PLANS. Ft, Floor Area 36906010.00 Required Inspections Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is forone hundred dollar( ($100) or less.) 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person . any ma ne ;o ��come subject to the Workers' Compensation Laws of Caliform ale L° Applicant ' NOTICE TO A LICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must ,J O forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY (~i iii I hereby affirm that there is a construction lending agency for the performance of CG r7 the work for which this permit Is issued (Sec. 3097, Civ. C.) a4A Lenders Name 0Z Lenders Address U 0 I certify that I have read this application and state that the above information is VL rr correct. I agree to comply with all city and county ordinances and slate laws relating to 0 V building conswction, and hereby authorize representatives of this city to enter upon the >.( aabove-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against .Hy to liabilities, judgments, costs and expenses which may in any way accrue against said City U '7 in consequence of the granting of this permit A APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: SOURCE REGULAq'IONS. I , Signature of ApplicanVContraclor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupantstore or handle hazardous material as defined by the Cupertino Munidipal Code, Chapter 9.12, and the Health and Safely Code, Section 25532(a)? ❑Yes (No 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 District? ❑ Yes '.No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Hcalth & Safety Codc, Secdons 25505, 25533 and 25534.1 understand that If the building does not currently have a tenant, that it is my responsibility to notify the occupant of the requi, encs * h must be mel prior to issuance of a Certificate of upancy. ilc Io Owner or authorized agent Date Re -roofs Type of Roof Type Date /� /__ 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'" or better