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BUILDING DIVISION PERMIT € �1� �Li ti'��J1tlY i1�1;
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BUILDIi�G�.)3r)g , PERMIT NO.
ORLINE CT —LOT 4 SHASHI LLC 07060020
OWNER'
10735 ORLI —
PHONE: SANITARY N CONTROL NO.
ARCI-IrfECT/ENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of -Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. e
Data Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public rccnrds
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alTnrm that 1 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 concoct, alter, 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
(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 penalty of
not more than five hundred dollars
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the stricture is not intended or offered for sale (See.7044, Business
and Professions Code: The Contnu-tor's License Law does not apply to an Owner of
property who builds or improves thereon, and who does such worst himself or through his
own employees, provided that such improvements are not intended or offered for sale. Ir,
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
concoct 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 conuacu for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B & P C for this mason
Owner Date
I y aQrm under pally of perjury one of the following de clamtionz
❑ 1 have and will maintain a Certificate of Consent to self-insum 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 end 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 Workers Compensation Insurance carrier and Policy number arc:
Carrier.
Policy No.:
CERTIFICATE OF EXEMP'nON FROM WORKERS'
COMPENSATION INSURANCE
Crhis section need not be completed if the permit is forone hundred dollars($100)
or Icss.)
I terrify that in the performance of the work for which this permit is issued, i shall not
employ any person in any manner te e subject to the Worters' Compensation
Laws of California_ its
Applicant
NOTICE TO APPL4 ANT: If,
become subject to a Workees Co nation provisions of the Labor Code, you must
forthwith comply with. such provisions or this permit shall be deemed rewokcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is at construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state thal the above information is
correct. I agree w comply with all city and county ordinaners and state laws relating to
building construction; and hereby authorim representatives of this city to corer upon the
ahove-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
SOURCE REGULATIO
C
Signatu . f Applicant/Conira r Da
MATERIALS DISCLOSURE OU
11 the applicertl fu building occupant store or handle hazardous material
as defined by the Cupertino Municipal c Chapter 9.12. and the Health and Safety
Code. Section 25532(a)7
Cl Yes o
Will the applicant or future build' pant use equipment or devices which
emit hazardous air contaminants as do d by the Bay Area Air Quality Management
District?
❑ Yew o
1 have read the haaardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 undcrsavrd thin if the bulking
does not currently have a acnanl, that it is my responsibility to notify the Occupant of the
requirements; hick in met