08020048CITY OF CUPERTINO
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BUILDTOIQp�EsSTEVENS CREEK BLVD PERMIT NO.
�j TBD - TO BE DETERMINED 08020048
OWNER'S NAME;
WDV PROPERTIES
PHONE:
ARCHnT,CTfENGWEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70013) of Division 3 of the Business and Professions Codc. and my Bee= Is
in fall fora and
Lieanae CI L.ie. N
Date Contraeior
ARCHITECTS DECLARA
I understand my plans shall be used as public records
Licensed Professional
OWNER-BUR_DFR DECLARATION
I herby affirm that 1 am exempt from the Contractors License Law for the
following moon. (Section 7031.5. Business and Professions Code. Any city or county
which requires a permit to corsstruct., alter, improve, dcmnlish, or repair any structure
prior to its issuarim 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 70f1(1) of Division 3 of the B usiness and Professions Code) or
dust he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any appliaot for a permit subjects the applicant to a Civil penalty of
not mom than five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work. and the structure is not Intended or offered for sale (Sex. 70", Business
and Professions Code. The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who ekes such work himself or through his
own employees, provided that such improvement& are not intended or offered for 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 not build or Improve for purpose of
sak.).
❑ L as owner of the property, am exclusively contracting with licensed comrac:tors to
construct the project (Sec. 7044, Business and Professions Code:) The Conttsetoes Li.
cerise Law does not apply to an owner of property who builds or improves th non, am.
who contracts for such projects with a contractor(s) licensed punnant to the Contractors
Ucenae Law.
❑ I am exempt under Sec . B & P C for this mason
owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Cenifiate 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
Q'T have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cote, for the performance of the work for which this permit is issued.
My Worker's Cmop__go"
iet�Nrana ce rrierr and Policy number am:
Carrier. Af- , 4W o" &;AIFi No.: Id
CE]=CAT E OF EXEMPTION FROM W O
COMPENSATION INSURANCE
(This section need not be compitied if the permit is for one hundred doom (S IOG)
or less)
I certify that in the performance of the work for which this permit is issued, I shall not
employ arty person in any maoncr so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: if, after mating this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby air= that there is t construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Landers Address
I certify that I 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 authoria representauvrs 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 tgaimrst
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of titles permit.
APPLICANT UNDERSTANDS AND OMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applian Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fulum building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cote. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑ Yes 5�Fo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminanss u by the Bay Area Air Quisity Management
District?
❑ Yes o
l have read the hazardous materials rcquiremene<de unr ter 6.95 of the Califor-
nia Health do Safety Code, Sections 25505, 25533 _ understand that Uthe building
does not currently have a umant.dos it ' responsibility to noufy the occupant or the
mquim which must h� to issuance of a Certificate of
PERMIT ISSUE DATE
02/08/2
SANrr,kRY NO.
ONE SET OF ILLUMINATED
.---- _ Jo
Sq. Ft. Floor Area
APN
Required Inspections
Issued by:
Re -roofs
Type of Roof
CONTROL NO.
BUILDING PERMfr INFO
ELECT PLUMB
on
Type
Date 2 —�
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
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or tuthorizcd azem / ( Date