07070244CITY OF CUPERTINO
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BUILDING DIVISION P�1'Ry�''JQla'
BUILDING ADDRESS:
PERMIT NO.
10251 S DE ANZA BLVD
GATEWAY BUILDERS
07070244
OWNER'
176 S
PHONE:
AR CONTROL NO.
(408) 687-6967
ARCHrrEC7/ENGTNEM
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
i hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
infull orcean00)ofDivision3ofmc8usine;sandProfrssionaCode,andmyiicenscis
in full force and effect
TENANT IMPROVEMENT —BUILD PARAPAT TO SEPARATE
License Class - Lic. a
OCCUPANCIES.
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
followinlg reason. (Section 7031.5, Business and Professions Code: Any city or county
_
which 'iequires,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
that he is licensed pursuant to the provisions of the Contractor's Litrnse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7W0) of Division 3 of the Business and Professions Code) or
-
3 O O 0
that he Is exempt therefrom and the basis for the alleged exemption. Arty violation of
i7,�,T Number
3 5 9 17 0 01 1
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 (I500).
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contactors License Law doe; not apply to an owner of
q
property who builds or improves thereon, and who does such work himself or dumugh his
awn employees, provided that such improvement; are not intended or offered fix 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 tot build or improve for purpose of
sae.).
❑ I. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Conuactoes Li-
cense Law does not apply to an owner of property who builds or improves tbermn, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contrurah
I ieease Law.
❑ I am exempt under Sec B & P C fortthiis rretso�n,
Owner Due IWY1 rt'7 U
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury are of the following declarations
❑ I have and will maintain a Certificate of Consc ut. to self -inure for Woftes Compen-
sation, as provided for by Section 3700 of the Labour Code, fox the performance of the
work for which this permit is issued.
❑ 1 have mA will maintain Worker's Compensation Insurance, its 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 Polity number art.
Carrier. Policy No.:
CEM IFTCAATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is ror one hundred dollars (S100)
or Less.)
1 certify ohm in the performance or the work for which this permit is issued. 1 shall not
..
employ any person in any manner
Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code you mew
' forthwith comply with such provisions or this permit shall be deemed revolted
1 "
' CONSTRUCTION LENDING AGENCY
I hereby aRrm that there Is a construction ending agency for the performance of
the work forwhieh this permit is issued (Sex. 3097. Civ. C)
I L.endersName-
Lenders Address
jI testify that I have read this application and state that the shove information is
t correct. I agree to comply with all city and county ordinances and state laws relating to
t building construction, and hereby
) g y authomp representatives of this city to enter upon the
above -mentioned property for inspection Purpose.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
1 liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT�(JNDANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date f
SOURCERE-- ,^ 11
Re -roofs
Type of Roof .
(�I k-'L
Signature of ApplieanXiml actor'Dole'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardotrs material
as defined by the Cupertino Municipal Codc, Chapter 9.12, and the Health and Safety
Code. OYoonn 25532(a)? o
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
Will the applicant or uture building omhpant.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 o
Ihave read the hazard m2tcrialsrequiremensunderChapter6.95oftheCalifor-
nia Health & Safety Code, Sections 25505. 25533 and 25534.1 understand that if the buRding
does not currently have t trnan at it is my resporisibility o nodfy the occupant of the
mquimment;'which must r to' anex of a Certificate of Om ry.
Signatureof Applicant Date
®
All roof coverings to be Class "$" or better
Owner orauthorizedagent Da