07030016BUILDING DIVISION PERP
iS: PERMIT N0.
N WOLFE RD TBD — TO BE DETERMINED 07030017
OWNER'S NAME; PERMIT MIME DATE
CUPERTINO SQUARE LLC 03/05/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
p zo LICENSED CONTRACTOR'S DECLARATION
V I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
] OM in full force and effect.
License Class Lic. #
F wDate Contractor
p,a ARCHITECTS DECLARATION
< I understand my plans shall be used as public records
5-W
'u. Licensed Professional
" y OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
p Oy� following reason. (Section 703 L5, Business and Professions Code: Any city or county
q {i which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant Cor such permit to file a signed statement
y < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
K F C1 (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 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 cam pensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does net apply to an owner of
property who builds or improves Ihercon, 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 Contractors Li.
cense Law does of apply to an owner of property who builds or improves thereon, and .
who contracts dpra'ecLs with a pritractor(s) licensed in to the Contractor's
License Law. J
❑ I am exe t n 8 & P C f Pthis eason
2 1
Owner Date/ _
CO ENSATION 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 Workers 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 Penni( is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the Permit is for one hundred doll ($100)
or less.)
I certify that in the Ars
of we c r whi4 is PC it ' •su I hall not
employ anyperson no c mos bjc to theWorlc sat(on
Laws of California. Applicant
NOTICE TO APPLICANT: If, a'ler making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
,J Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
[~—(� I 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.)
W A Lender's Name
,z Lender's Address
U 0 1 certify that I have read this application and slate that the above information is
w t' -r correct. I agree to comply with all city and county ordinances and state laws relating to
Q U building construction, and hereby authorize representatives of this city to enter upon the
a ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rA liabililies,judgments, costs and expenses which may in any way accrue against said City
U Z in consequc a of the granting of thi permit.
r"t APPLIC NDERST�p DS NO WILL COMPLY WITH AL %0NOINT
SOU Ulyt( 9tQ.
Signature of Appiican o actor Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Muni ipalfode, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)?
❑ Yes Nu
Will the. applicant or future build p occupant use equipment or devices which
emit hazardous air contaminants as reed by the Bay Area Air Quality Management
District?
C] Yes ❑ N.
"d
have read the hazardous materials requirements under Chapter 6.95 mf the Califor-
niaHealth&Safety Code, Sections 255 5,25 33 and25534.Iundersand haliChe ilding
does not torten a tenari itis y responsibility to notify the occup t of the
requirement K mu 1 be mil ort t 'trance of a Ccnificatc-4 cu an
Owner or authorized at.ent Date '
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
Job Description
TEMP PERMIT—WEST ENTRANCE EXTERIOR MALL—ORIGINAL
PERMIT #07020028 PERMIT EXPRIES
4/5/07—DIVITTORIA CONST PD FOR BUS LIC 3/5/7
Sq. Ft. Floor Area I $ 0
31620037`,
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
Valuation
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