09050015CITY OF CUPERTINO n��-�*
BUILDING DIVISION PEitLYu rowl
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t. Jk �Sti
BUILDING ADDRESS:
PERMrr NO.
10431 N DE ANZA BLVD
DEVCON CONSTRUCTION INC
09050015
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
AVAV O. CONTROL NO.
(408)942-8200
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Pr fessions Code, and my license is
in full face and effect I G3
COM' L TI 1ST&2ND FLR & INTERIOR DEMO (3 8,, 811) CONF
,"'7 pas uc.x IV
Dale � Contractor
RMS, OFFCS, FINISHES, FIXTURES& ACCESSBILTY
ARCHITE(_TS DECLARA ON
I understand my plans "I be used as public records
UPGRADE; L IMTD SITE UPGRADE CONSISTING OF
WALKWAYS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hcmby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.S, Business and Professions Code: Any city or county
which requires a permit to construct, altry improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that. he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3 5 0 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption Any violation of
APN Number
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars (S-SM).
32633114 . 00
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the worm and the structure is not intended or offered for sale (Sec. 71144, Business
and Professions Code; The Contractors 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 employ=, provided that such improvements ace 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 Ll-
cc= 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 Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 here and will maintain a Certificate of Conacnt 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 Ibis permit is isctced.
❑ 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 Compensation Insurance carrier and Policy numb are: O
U ( G W No.:
r
Carrie. Polity
CERTIFICATE OF EXEMP 71ON FROM WORKERS'
COMPENSATION INSURANCE
('his section need not be completed if the permit Is for one hundred dolars (SI00)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in sny manner so as to become subject to the Workers' Compensation
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If. alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such previsions or this permit shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that them Is a construction lending agency for the performance of
i the work for which this permit is issued (Sec. 3097, Civ. C)
Lenders Name
,
Lenders Address
i I certify that I have read this application and state that the above information is
correct 1 agree to comply with all city and county ordinances and state laws relating to
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
j Iiabilitics,judgmenta, costs and expenses which may in any way accrue against said City
' in consequence of the granting of this permit
APPLICANT UNDERSTAND ND WILL COMPLY WITH ALL NON -POINT
Issued b Date
y.
SOURCE-REGULA ONS.
/I
Re -roofs
Type of Roof
Signature ofApplicant/Con or Data
US MATERIA DISCLOSURE
Will the applicant o utum building t store or handle hwardous material
as deemed by the Cupertino unicipal Code. aptcr 9.12, and the Health and Safety
Code. section25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes o
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
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia i-lalth & Safety Code, Soetlons 25505. 25533 and 25534.1 understand that if the building
does not currently hats: a tenant, it � my responsibility o nodfy the o pant of tiro
require is which m Ir mr or issuan fa.Ceriratc of
Signature of Applicant Date
�-
All roof coverings to be Class 'A" or better
Date
Owner or authorized agent