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CITY OF CUPERTINO ,
BUILDING DIVISION PERMIT{3RFt}R1GIie�IQN:
BUILDING ADDRESS: PERMIT NO.
�0573 STEVENS CREEK BLVD TBD - TO BE DETERMINED 08060208
_ SANITARY NO, CONTROL NO.
ARCHITF.CT/ENGINEERR BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Profession Code, and my liters: is
in full force and effecL l.'cen 33 , x
Date Contractor vl,
ARCHrIECPS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from rite 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, after, improve, demolish, or repair any strucum
prior to its issuance, also requires the applicant for such permit to file a signed statement
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 Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (S500).
0 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 site (Sec. 7044, Business
and Professions Codc_ The Contractor's License Law darts not apply to an owner of
property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements are not intended or offered for ale If,
however, the building or improvernent is sold within one year of completion, the owner•
builder win have the burden of proving the he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed conoactms ter
construct the pmjcct (Sec. 7044. Business and Professions Code:) The Contractor's U
tense Law does not apply to an owner of property who builds or improves thereon, arc
who contracts for such projects with a eontracior(s) licensed pursuant a the Contractoei
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following deelamtions
❑ I him 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 th
work for which lids permit is issued.
EVI have and will maintain Worker's Compensation Insurance, is required by Sectioi
3700 of the Labor Code, for the performance of the wort for which this permit is issued
My Workers omati pensou
No.: A b,3
CERTIFICATE OF EXEMPTION FROM W ORKE S'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100
or Less_)
I certify that in the performance of the wort for which this permit is issued, I shall nc
employ any person in any manner so as to become subject to the Workrtt Compensator
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If, after mating this Certificate of Exemption. you shoub
become subject to the Worker's Compensation provisions of the labor Code, you mw
forthwith comply with such provisions or this permit shall be deemed ranked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm the there is a construction lending agency for the performance e
the wort for which this permit is Issued (Sox. 3097, Civ. C.)
Lenders Name
Lenders Address
1 =iffy that I have read this application and state that the above information i
corccr. 1 agree to comply with all city and county ordinances and sate laws relating t
building construction, and hereby authorize representatives of this city to enter upon !h
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino again
liabilites,judgments, cots and expcn= which may in any way accrue &grist said Cr,
in consequence of the granting of this permit.
APPLICANT ALL NON -PAIN'
Job Description
INSTALL WALK UP ATM MACHINE-WASHINGTON MUTUTAL
BANK.
METROPOLITAN LIFE INS OWNS BUILDING.
Re -roofs
the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.IZ and the Health and Safety
Code, Section 25532(a)7 ❑Yes &No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or dcvixs which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as damned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑ Yes �No
I have read the hazardous materials requirements under Chapter &95 of the Califor-
nia Health & Safety Coda Sections 25505.25533 and 25534.1 understand dun if arc building
does