08080146c BUILD NG DPERNNU PERMIT C�N7� CTQR Y U N Ax O <I
BUILDING ADDRESS: PERMIT NO.
1.0123 N WOLFE RD TBD — TO BE DETERMINED 108080146
OWNER'S NAME: PERMIT ISSUE DATE
— -- NE --
CUPERTINO SQUARE LLC 09/19/2008
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
P4 O LICENSED CONTRACTOR'S DECLARATION
U C I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
Z m with Section 7000) of Division 3 of the Business and Professions Code, and my license is
a y in full force and effect.
License Class Lic. p
w Date Contractor
ARCHMCPS DECLARATION
I understand my plans shall be used as public records
10.0
' w I"' Licensed Professional
10 a OWNER -BUILDER DECLARATION
ia I hereby affirm that 1 am exempt from ilio Contractor's License Law for the
p O following reason. (Section 7031.5, Business and Professions Code: Any city or county
C $ K which requires a permit to construct, alter, improve, demolish, or repair any structure
r prior to its issuance, also requires the applicant far such permit to rile a signed statement
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
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 penally of
not more than five hundred dollars ($500).
❑ I, 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 Codec The Contractor's License Law docs not apply to an owner of
property who bp ifdsorimprovesthereon,andwhodoessuchworkhimselforthroughhis
own emplo e6s, provided that such improvements anot intended or offered for sale. If,
however re a building or improvement is sold within one year or completion, the owner -
build ill have the burden of proving that he did not build or improve for purpose of
6 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 docs not apply to an owner o(property�vh0 builds or improves (hereon, and ,
who contacts for sue rot cls w'd' co traclo ,�f) licensed pursuant to the ontra lot's
License Law.
❑ I am ezamplry�td r r I , B& P C or1[tis on
..s i
Owner If u #_11 E """
P ORKER' CO SATION DEC LARATIO
I hereby affirm under penally 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 Workers 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 arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Rtis section need not be completed if the permit is for e�,,Ourlrsd dollars ($100)
nr less.)I certify that in the perfo c the wo fo i this pc i ucd, l shall not
employ anyperson in any '� nr s astm est ' Etto ,' Compensation
Laws of California. Datc
Applicant _,—
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Ichor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
GY �✓ the work for which this permit is issued (Sec. 3097, Civ. C.)
(3� A Lender's Name
�+ ess
Z Lender's Addr
U 0 I certify that I have read this application and state that the above information is
LL H correct. I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
Hy fn liabilities, judgments, costs and expenses which may in any way accrue against said City
U.'z in consequence of the gpg f this p
—+ APPLICANT UN S Ka�S A W 1C0 Y WITH ALL NON OINT
SOURCEREGUL N
Signature ofApp Contractor te
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mu9i
Code, Section 2apal Code, Chapter 9.12, and the Health and Safety
5532(a)? !/
[:1 Yes •❑No
Will the applicant or future ding occupant use equipment or devices which
emit hazardous air conlamman da incd 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 Health & Safety Code, Sccdo O5, 25533 an 534.1 understand that if the building
does not cu rte a ren That 1. 25 r nsrhility to notify the occupant of the
maulmmnnls rl�t be melon r�tohssua of a Certificate of Occupancy.
Owner or) uth rizad agent v t Data*
Job Description
WAFFL SLB RPR @EXTNG UCB LOCTN
Sq.
31620096.
Issued by:
Re -roofs
Type of Roof
Area
$100
Required Inspections
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 neve ma ri s for eection
f
Signature of Applicant Da
All roof coverings to be Class'n" or better