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BUILDING DIVISION PERMIT GE10=F�y
BUILDING ADDRESS: PERMIT NO.
20299 STEVENS CREEK BLVD TBD - TO BE DETERMINED 07120255
OWNER'S NAME: PERMIT ISSUE DATE
: SANITARY NO. CONTROL NO.
ARCHI'IECT/ENGiNEER: BUILDING PERMIT' INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 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. N
Date Contractor
ARCHn'ECrS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm 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 construct, alter, improve, demollsIL or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed stskuncot
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 Businrssand Professions Code) or
that he is exempt therefrom and the basis for the aUegcd exemptan. Any violation or
Section 7031.5 by any applicant [Of a permit subjects the applicant to a civil penalty of
trot more than five hundred dollars (SM.
❑ L 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 ask (Sec. 7044, Busim a
and Professions Cade: The Conuamor's 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 improvements are not intended or offered for sale. If.
however, the building or improvement Is sold within one year of completion, the owner-
buildcr will have the burden of proving that he did not build or Improve for purpose of
sale.).
XI, as owner of the property. am exclusively contracting with licensed contractors to
contract the project (Sec. 7044, Business and Profession Code.) The Contractor's U-
tense 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 Contractor's
License w.
❑ 1 am excm t under S
1 hereby atrrrm un r penalty or perjuryone of the following declarations:
❑ I hove and will maintain a Certificate of Consent to self-inum [of Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
worts for which this permit is issued.
❑ 1 have and 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 Worker's Compensation Insurance carrier and Policy number are:
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for anc hundred dollars ($100)
or less.)
I certify that in the performance of
Exemption, you should
become subject to the Worker's Compens4don provision of the Labor Code, you must
forthwith comply with such provision or this permit shall be deemed rooked
CONSTRUC130N LENDING AGENCY
1 hereby affirm that there is a consutiction lending agency for the performance of
Lire work fur which this permit is issued (Sec. 3097, Civ. Q
Lender's Namc
L.ender's Addresf
1 certify that I have read Lida application and state that the above information is
correct 1 at= to comply with all city and county ordirimms and slate laws relating to
building construction, and hereby authori?e teprtsenrarives 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• costs and expenses which may In any way accrue against said City
in consequence of the granting of this p=IJL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
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HAZARDOUS M TERiALS DISCLOSURE
future
Will the applicant or buil ng occupant store or handle hazardous material
as damned by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ YesNo
Will the applicant or uttue building occupant use equipment or d'vlces which
emit hazardous air contsminants as defined by the Bay Area Air Quality Management
District?
❑ Yes N0
t
1 have mad the hazardous materials requ mments under Chapter 6.95 ofthe CaFror.
nia Health & Safety Code, Section 25505.25533 and 25534.1 understand that if the building
don not currently have a tenant, that it is my reason ibilhy to notify the occupant of the
requirements be
DEMOLITION 4,382 SF
q. Ft. Floor Area
316 2. 5 0 4 2 My Number
Issued by:
Re -roofs
Type of Roof
Job Description
$3000 Valuation
Required Inspections
Occupancy 'lj pe
Date
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