05090158j CITY OF CUPERTINO
BUILDING DIVISION P
BUILDING ADDRESS:
10150 N WOLFE RD
ER'S NAME: OWN
JC PENNEY
160 DRY CREEK RD
PERMIT ISSUE DATE
04/05/2006
PHONE: SANITARY NO. CONTROL NO.
(928)282-7554
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 LICENSED CONTRACTOR'S DECLARATION
to P:I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U w with Section 7000) of Division 3 of the Business and Profession Code, and my license is
y in full force and effect.
? License Class Lic. tf
;:in Dale Contractor
ARCHITECTS DECLARATION
a I understand my plans shall be used as public records
�yU
4 C, y Licensed Professional
< OWNER -BUILDER DECLARATION
u a 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
io 0 following reason. (Section 7031.5, Business and Professions Code: Any city or county
e „ [i, which requires a permit to construct, alter, improve, demolish, or repair any structure
ti prior to its issuance, also requires the applicant for such permit to Ole a signed statement
_zr
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
YF (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
i 3 that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more 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 (Sec. 7044, Business
and Professions Code: The Contractor'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 i mprovemems 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
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense 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 Law.
❑ 1 am7t u der Sec. 1 , B & P C for this reason
Owner �W��/1
WORK C'U PE SAT ON DECLARATIO
I hereby affirm under penally of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent toself-insure for Worker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I 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 arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this Srmit is issued, 1 shall not
employ any person ty nc o, to.b o e subject t he Workers' Compensation
Laws of Califoptta. D a/ _
Applicant A-'
NOTICE T [ , after ma tin this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
'z V) CONSTRUCTION LENDING AGENCY
..
I hereby affirm that there is a construction lending agency for the performance of
CL ^✓ the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lender's Name
Lender's Address
az
U Q 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
O U building construction, and hereby authorise representatives of thiscity to cmerupon the
U above -mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
Hrn liabilities, judgments, costs and expenses which may in any way accrue against said City
U z in conse of the granting of this permit.
APPLI ANT NDERSTANDS AND ILL COMPLY WITH ALL NON -POINT
SOURCE RE , LATI
1 t - ApplicanVCont actor Date
HAZARDOUS MATERIALS DISCLOSU
Will the applicant 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, Section 25532(a)?
❑Yes ❑No
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
District?
❑ Yes ❑ No
I have read the)hp,7.SarCd(,)us materials requirements underChapter tS.95 of the Cali for-
niaHcalth &Safeyons 25505,25533 and 25534.1 understand that if the building
;does not curre avc tenant that it is my respogsihility to notify the occupant of the
Job Description
TI-MIN PARTIT/BELOW CEILING/NO STRUCTURAL
COSMETIC/CARPET/PAINT/MEC/LIFE SAFETY (PHASE II
4/4/6 REFUNDED (16,150.82) TO MELISSA WAGNER.PE
Sq. Ft. Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
v410iq000
Occupancy Type
Date r �,fi_C; 6
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.
agent
Signature of Applicant
Date
All roof coverings to be Class "B" or better