08050170lelz
10,
.nw
rz
e0Uy
�o�
N
p0
-Zt
2.
'59
.7 C
U
Liz >
UC
LL �
C Cr
CL
�y V.
U2
CITY OF CUPERTINO r7��
"a" :..
:"'
BUILDING DIVISION PG1tlYlly
BUILDING ADDRESS:
PERMrr NO,
10168 N PORTAL AVE
TBD — TO'BE DETERMINED
08050170
OWNER'S NAME;
FERMI r WIM DATE
MR &
22/2008
PHONE
SANITARY NO, CONTROL NO.
ARCHITECT/ENGiNEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I ate licensed under provisions of Chapter 9 (commencing
with Section 7000) o[Division 3 of the Business and Profession& Code, and my licar"a is
RMDL 2BTHS (80SQ) KTCHN (100SQ) RCOPPR MAINLINE,
in full forte and efrect `7 2
r r
License Class L,•+ �s�
NON—STRCTRL&WNDOW RPLCMNTS LST HOLDINGS PDBUS LIC
Deto�1 Con lnactor
ARCAITECPS DECLAR,+
5/ 2 2/ 8 # 010 0 0 0 4 0 6 6 0
1 understand my plan hscd aspas fit rcrnrds
Licensed Prof
NER- ER D RATION
I hereby affirm that pt from the Contractors License Law for die
following season. (Section 7031.5, 4usiness and Professions Cork: Any city or county
which requires a permit to construct. alter, improve, demolWn, or repair any structure
.
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
8 0 0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
` Number
Occupancy Type
Seaton 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
31628053 ..
❑ 1. as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the SMXI a is trot Intended or offered for sale (Sec. 7044. Business
and Profession Code: Tbc 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 employees, provided that such improvemerita are not intended or offered frosak. If,
however, the building or improvement is sold within one year of completion, the owrrs-
builder will have the burden of proving that he did not build or improve for purpose or
sale.).
.
❑ I. as owner of the property, am exclusively contracting with Grztued contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense law does not apply to am owner of property who builds or improves thereon, and
who conuacts 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
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have 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 performance of the
work for which this permit is issued.
❑ 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 permitjjjIt Issued
My Worker's �pensau�Ltwpnce carrier and Policy num� n
Carrier TG/J/1 Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION WSURANCE
(This .section need not be completed if the permit Is forone hundred dollars (SIDO)
or less.)
1 cerufv that in the performance of the work for which this permit is issued, I shall no
-
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption,.you should
become subject to the Workers Compensation provision of the Labor Code, you must
forthwith comply with such provisions or this pesrnit shall be deemed revoked.
CONSMUC71ON LENDING AGENCY
I hereby alum that there is a eonstnwdon lending agency for the performance of
the worst for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lenders Address
I certify that I have read this application and sate that the above Informaton is
correct I agree to comply with all city and county, ordinances and state laws relating to
building construction, and hereby authorim representatives of this city to cuter upon the
above-rnentoned property for inspection purposes
(Wc) Rgree to save, indemnify and keep harmless the City of Cupertino sga =
liabilities, judgments, toss and expemws 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
Issued by: Date Z / i 4
SOURCE REG
DISCLOSURE
Will the appli t or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Belies 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
El Yes ❑ No
If a roof is installed without first obtaining an inspection,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
.I
all new materials for inspection.
DLunc%7
❑Yes ❑No
I have read the hazardous materials requhentonts under Chapter 6,95 of the Califor-
ni1 Health & SafctyCodc rs 25505.25533 and 25534.1 understand thnif ilm building
does not currency have a an that a is m asibility to notify the occupant of the
requirements which mess reel ussu of a Ccrufhcato
Signature of Applicant Date
All roof coverings to be Class'JV' or better
Owner Dater '
or authorimd agent