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CITY OF CUPERTINO
BUILDING DIVISION PERMIT�JJ�tCl}Lj�>4�fllQt►l'.
:
BUILDING ADDRESSL
PERMIT NO.
10036 ORANGE AVE
TBD - TO BE DETERMINED
07110167
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
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 70ao) of Division 3 of the Business and Professions Code, and my license is
C01v1M r L T I , ADD PARTN WALL IN CLINIC UN I T
in full force and effect.
License Class Llc. 0
Date Contractor
ARCHf1EC1'S DECLARATION
1 understand my plats shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions of the
(commencing with Section 7000) of Division 3 of the Btsinessand Professions Code) or
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$ 5 0 0 0
that he is exempt therefrom and the bass for the alleged exemption- Any viostfon of
Number
um
Occupancy
T 'pe
Section 703I.5 by any applicant for a permit subjects the applicant to a civil penalty of
ant more than five hundred dollars (S-Wa
3 5 717 0 5 9 .`
❑ L as owner of the property, or my employees with wages As their sole compensadon,
Required Inspections
will do the work, and 11W structure is not intended or offered for sake (Sec. 7044, Business
and Professions Cede: The Contractors Littnse Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such Improvements are not intended or offered for sale If,
however, the building or improvement is sold within one yew of completion, the owner -
builder will have the burden of proving that he did rot build or improve for purpose of
sale.).
. as owner of the property, am exclusively contracting with licensed contractors to
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onstmct the project (Sec 7044. Business and Professions Code:) The Contractors Li-
.
ccnse 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
DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I here and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performan c of the
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work for which this permit is issued- -
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❑ 1 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 are:
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Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if tea: permit is Rrrone hundred dollars (SIOO)
or less.)
I certify that in the performance of the work for which this permit Is issued I shall not
employ any person in any manncrso,pess to becon subject to the Workcs' Compensation
Laws of Cali��mu} r4 � �N," , /
�D�re�
Applicant k ; Cr�v t• c
NOTICE TO APPLICANT: If, afte making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
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forthwith comply with such provisions or this permit shall be deemed revoked -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is • construction lending agency for the performance of
the work for which this permit IS issued (Sec, 3097, Civ. C-)
Lenders Name
Lender's Address
1 certify that 1 have read this application and state that the above information is
correct. I 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
liabilities, judgments, toss and expenses which may In any way accrue against said City
in consequence of die granting of this permit -
APPLICANT UNDERSTANDS AND WILL COMPLY WITH All. NON -POINT
J l%�
Issued by: Date
SOURCE R GULATIONS.
Re -roofs
Type of Roof -
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fut,.m building occupant store or handle hazardous material
as dined by die Cupertino Municipal Code, ❑ &peer 9.12, and the Health and Safety
Code, section25532(a)7
El Yes e�CjNo
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 future building ocnrpant use equipment or devices which
emit hazardous air contaminants as dermcd by the Bay Area Air Quality Management
all new materials for inspection.
Disrict7
❑ Yes JONo
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I have read the hazardous materials requirements under Chapter Q95 of the Califor-
nia Health & Safely Code, Scciio s 25505, 25533 and 25534_ I understand ohm if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
Mquimments which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner -
orauthorized agent Date
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