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CITY OF CUPERTINO
DIVISION PERMIT�1I'Rt�QiI�ON'_
BUILDING
BUTLDII;(Cr,q.QD12ES,S; WOLFE RD # 3 0 0 0
1NAGM.SE: lV
TBD TO BE DETERMINED
PERMIT NO.
0 8040052 ,
OW NEERUS
PERMIT ISSUE DATE
CUPERTINO SQUARE LLC
04/08/2008
PHONE:
-
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 arthe Business and Professions Code, and my license is
ILLMNTD INDVIDL CHANNL LETTR STR FRNT SGN W/EXPSD
in full force and effect.
License Class _ Lia k
NEON
Date o Co tractor
ARCHITECTS DECLARATIO
I understand my plans shall be used az 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 construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Contractor's License law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the (Chapter
$25-00
(commencing with Section 70(10) of Division 3 of the Business and Professions Code) or
that.he is exempt therefrom and the basis for the alleged exemption. Any vimlation of
316 2 0 0 3 7 : dumber
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 az their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7D44, 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 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li.
cease 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.
F'1I am exempt under Sea , B & P C for this reason
Owner Data
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.
,
My Worker's Con pen anon Insurance c rricr and Policy number are:
Carrier, . Policy No.: 910 `f'(T R
--J'-7
CERTIFICATE OF EX MPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc 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 az 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 of the Labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
' CONSTRUCTION LENDING AGENCY
+ I hereby acorn that there is a construction lending agency for the performance of
y the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
y building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,
—
Re -roofs
Type of Roof
-
Signature of Appaa7nt/Conlractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
[:)Yes
All roofs shall be inspected prior to any roofing material being installed.
g'�0
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?
❑Yes Iu
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Cc dc, Sections 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 or the
requirements which must be met primr to issuance or a certificate of Occupancy.
Signature of Applicant Date
�--� �w�'�`°�
All roof coverings to be Class "n" or better
-
Owner of authorized agent Date '