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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
5 INFINITF, LOOP
NOVO
OWNER'S NAME:
PERMIT IS6UE DATE
PHO
S A CONTROL NO.
650)701-1500
ARCHTTEcTIENGINEM'
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 Divison 3 of do Business and Professions Code, and my license is
in full force and eff
COMM'L TI INTER OFFICE REMODOL, NON—STRUCTUR
Llcc= Lk. M
Date contractor Wave Guc
INCLUDNG MECH& ELECTRCL (18 8 6 4 SQ )
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Pmfasional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Btsincas and Professions Code: Any city or county
which requires a permit to construct, alter, tmpnra, demolish, or repair any structure
prior to is issuance, aso requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's I ,-nw Taw (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
15 0 0 0 0 0
APN Number
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than flue hundred dollar (SS00).
31602109.05
-
❑ 1, as owner of the property, or my employers with wages as their sole compemsation,
Required Inspections
will do the work, and site structure is not intended or offered far sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an Owner of
property who builds or improves theroon, and who does such wort himself or Ihmagh his
own employees, provided that such improvements are not intended or offered formic. lf,
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.).
❑ L 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 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
Lkt= Law.
❑ 1 am exempt under Sec. , B R P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 herby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Ceniflcate of Consent to self -Insure for WoftesCompen-
cation, 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 Compeuation insurance, as required by Section
3700 of the Labor Code, for do performance of the work for which this permit is laved
'
My Workers Compensation Insurancr, currier and Policy number am:
C.".WJWIC �.IlOirl I%t y Policy No.: j s �7
CERTIFICATE OF EJ PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (f 100)
or Less)
1 certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any masncr so ss to become subject to the Worttrs' 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.
CONS TRUCION LENDING AGENCY
I hereby affirm that there is a consumction Lending agency for the performance of
the work for which this permit is lasted (Sec. 3097, Clv. C.)
Lendcrs Name
Lenders Address
I certify that I have read this application and state that the above information is
'
cornet. 1 agree to comply with all city and county ordinances and state Taws 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
liabilities, judgments, costs and expenses which may in any way accrue against said City
in corsequeriee of the of this permit.
granting
APPLI ERSTANDS AND WILL COMPLY WITH ALL NON•POINT
Issued by; Date U=
CE REGU TTO
Re -roofs
Type of Roof
1 4
Sig of Applicant/Conlractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haumdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
[3 Yes ffiNo
All roofs shall be inspected prior to any roofing material being installed.
1
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 634Yo
I have mad the hararda/u'marcrisis requirements under Chapter 6.95 of the CaRfor-
nia Health k SafctyCode, Secdas 25505.25533 and Z5534.1 understand that if the building
don not c aver a t it is my responsibility to notify the occupant of the
ns whi muss me pn r to • of a Ccrtifcac of Oc an .
Signature of Applicant Date
D
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All roof coverings to be Class'%l�" or better
authourcd agent Dare