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03090020 & 04010129;ed, OO SFO ,�u :los ?00 3m� :ZLR =FG CI'T'Y OF CUPF.R'T'TNO ',Vit^•.a k'�4a *-"sR BUILDING DIVISION PERMIT CONTRACT,OR�NFOIZMATIONN�;, w BUILDING ADDRESS: AN KY CONSTRUCTION CO PERMIT N003090020 0 1956 HOMESTEAD RD :R'S NAME: 2530 BAMS I LN PERMITLSSUEDATE AFFINITY ENTERPRISE GROUP NC 10/24/2003 HONE (408)234-2673 SANITARY NO. CONTROL NO. ARCHITEC (ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MF.CH M t� 0 0 LICENSED CONTRACTOR'S DECLARATION' OeSCrI Ib Description P reby affirm that I licensed under provisions of Chapter 9 (Commenting I Mam with Section 9mn of Division 3 of the Business and Professions Code. and my license is wy p inmBlnreeandeffeet. TENANT IMPROVEMENT III O ALaEC License Class Lic.0 Date Crnuaeon ARCHITECTS DECLARATION rCp � a ayoo� FEB 1 understand my plans shall M ..ties Public records D L BUILDING Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that I out exempt from the Contractor's License Law for the following mason. (Section ]11]1.5. Business and Professions Cade: Any city or county which requires a Permit it consumer. alter, improve. demolish or repair any structure $18690 prior to its issuance, also respires the applicant for such permit to file a signed statement Sq. Ft. Floor Area Valuation that he is lice noted prmonr to the provisions of the Contractor's License Law (Chapter 9 (commencing with Sealon7")ol Division 3 of the Business and Professions Code)ur 32609061.00 al k exempt thereand the huh the for alleged exemption. Any violation of Nu from APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally of not mor. than fire hundred dollars MUD. I, u owns of uM property. or my employe. with wages u tear arN Compensation, Required Inspections will do the work, and me&uuettre is net ntended oroffered tet sale (See ]B44, Business and Professions Code: TT. Conunctors License Law docs not apply to in owner of q P property who build& or impnws thereon, and who does such work himself or through his Own employee, provided that such improvements arc mol intended of offered for sale. If. however, the building or improvement is sold within one year or completion, the owner - builder will have the burden of proving that he did not Wild or improve for purpose of I. as owner of tc propcny, am exclusively contracting wit Licensed conlnClr6 to sumet the project (Sec. ]Bd4, Business and Professions Code:) The Contractor's Li. me Law does not apply to in owner ofproperty who builds or improves themon, and who contracts for such infamous with aconuamor(s) licensed pursuam to the Canuacu r'a License Law. ❑ I am C' cmPL under Sec. . B 6 P C for this reason Dille /o3 WOkKER'S COMPENSATI D LARATliaNd 1 hereby affirm under penally of perjury one of the following declarations: I bare and will maintain A Certificate rf Consent m xl6iuum for Workces Compcm ration, u provided for by Section 37M of the labor Code. for d o performance of me work for which this permit is issued. r, I have and will maintain Worker's Compensation Insurance, u required by Section 311 of the Labor Cade. far IM performance mit of the wart for which this peri& issued. My Worker's Compensation Insurance carrier and Policy number ate: Cartier: Policy No.: CEUIFICATE OF EKEMPnON FROM WORKERS' COMPENSATION INSURANCE (This sectinn need nut M eom,leted rtM Permit is for one hundred dollars ($I00) less) I certify Nal in the perrmmance of the work for which this permit is issued. 1 shall not employ any Person in any manner so as to Mcome subject o the Workers' Compensation Laws of Calirmom. Date Applicant NOTICE TO APPLICANT: If, after making this Ccnificate of Exemption, you should become subject to the Workeis Compensation provision of the Labor Chile, you men forthwith comply with such provisions no this Permit shall M deemed revoked. CONSTRUCTION LENDING AGENCY at there is a Consction lending agency for e Performance of I Mmhy affirm ConstructionN Ric issued for which this peemir is issd (Sec. 709], Civ. C.) �. Lender's Name Lc landcrs Address I certify that 1 haw read this application and sum that the above information is ' comm. I agree to comply with all city and county ordinances and scale laws belating in building construction, and hereby Authorize mprescnutives of this city to enter upon the ahovc-mention cal properly for inspection purposes. (We) agree Ir save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expo rams which may in any way same against said City in consequence of the granting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE EGU Ng. 106(/D3 Re -roofs Type of Roof sign 'rc ofAppu ami t/Conrracwr DBte HAZARDOUS MATERIA SCLOsS Will Ne applicant of future Wilding occupant store or n charallousmateind deftncd by the Cupertino Municipal Code, Chapter 9.11, and the Health and Safety . Sc❑uionn 255320)? All roofs shall be inspected prior to any roofing material being installed.YC. A N. 1 If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or furore Wilding acupant use equipment or devices which emit hazardous air contaminants as dcfncd by the Bay Arca Air Quality Management all new materials for inspection. Disric" �[ ❑Yes Ip No - 1 have mail Nc hovardous materials requirements under Chapter 695 of the Califnr, nie HcalN6SafctyCWe. Section 25N15,25577 and 25534.1 undersand Nmif the Wilding J<cA not currently haw a tcnanl. Nat it u my rnponihility m notify IM acupant of the requi en wMmmaAIMmec urif sananarfaCe ¢ofOcaparty. Signature of Applicant Date l4zs/v3 All roof coverings to be Class "B" or better Owner omcd.,ont Das L CITY of CUPERTINO �;ITY OF CUPERTINO PERMIT APPLICATION FORM n n w 90Dzo APN #Date: Fee Description Fee Group BAPPLOTHER Building AddreZ5, �70 ' 5 (7�# A I&O&AID to. Owner's Name:. %�IN►jy �v7rslZP� � Q F INS. Phone #: � C '743 3/, SV S' Contractor: Boiler <= 100,000 Btu MECHANICAL License #: Contact: Zwh 12l. MECHANICAL BBOILER3 Cupertino Business License#: Buil ng Permit Info: I I Bl ❑lect ❑ BBOILER4 lamb M �W ob Descriptior Residential ❑r --J BBOILER5 Commercial ❑ Sq.Ft. Floor Area: boo j Construction Tax $/Sq.Ft.: Cost of Project: Ind/Off/Comm/Quasi BUILDING Occupancy Group: Type of Construction: BUILDING BCONSTAXH Hotel and Motel —r-1 Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC 1000 Elec 600V <= l OOOA ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 'ITY OF CUPERTINO Cm OF PERMIT APPLICATION FORM CUPEKFINO Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUIVIULTI New Multifamily Res PLUMBING BNUSFD New Single Family Res BUILDING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water HeaterNent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL 2 of 3 I aa :ITY OF CUPERTINO Cin of PERMIT APPLICATION FORM CUPEKrINO Quantity Fee ID Fee Description Fee Group BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT -Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING r BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECLU Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 3 of 3 0 z w 04 U w H U CITY OF CUPE BUILDING DIVISION PERM BUILDING ADDRESS: AN KY CONSTRUCTION CO PERMIT NO04010129 OWNER'S NAME: PERMIT ISSUE DATE AFFINITY ENTER PHONE: SANITARY NO. CONTROL NO. (408)234-2673 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I 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 cull force and erred. REVISION --HANDICAP PARKING License Class Lic. N Date Contractor NO NEW PERMIT ISSUED/ORIG. ##03090020 ARCHITECTS DECLARATION . I understand my plans shall be used as public records enscd Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the following reason. (Section 703 1.5, Business and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any structure 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 Sq. Ft. Floor Area Valuation $0 (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 APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). 32609061.00 ❑ I, as owner of the property, or my employees with wages as their sole compensation, Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: "fie 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 improvements are not intended or offered for sale. If, however, the building or improvement issold within one yearof completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of. sale.). ❑ I, 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 docs 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 am exempt under S, , B & P this reason frC�for O cr Datc G WORKER'S CEN ATION DECLARATION I hereby affirm under pena erjury oncof t dllowing declarations: ❑ 1 have and will maintain a Certificatcof Consent to self -insure for Worker's 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 permit is issued. My Worker's Compensation Insurance carrier and Policy number am: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Kris section need not he completed if the permit is for one hundred dollars ($100) or less.) 1 certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in any manner so as to become subject to the Workcrs' Compensation - Laws of California. Date Applicant , NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such or this shall he deemed revoked. provisions permit CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address / 1 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 authorise representatives of this city to enter upon the ahove-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 permit. / APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE RE TIONS. Re -roofs / Type of Roof . nature of kpplican L/CqKAIetor -,� Date HAtAPOUS MATERIALS DISCLOSURE Will the applicant r future building occupant store or handle hazardous material . as defined by the Cupertino Municipal.Code, Chapter 9.12, and the Health and Safety Codc.S 25532(a)? ❑ Yes �Nu Yes 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 Will the applicant or future building occupant use equipment or devices which emit haz.ardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for Inspection. District? ❑ YesI�tvu `materials I have read the hasardous requirements under Chapter 6.95 of the Califor. nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand that if the building . docs not currently have a tenant, that it is my responsibility to nosily the occupant of the requirements wIt must be met prior to issuance ofaCcniG are or Occupancy. Sigpature of Applicant Date _ All roof coverings to be Class "B" or better wn ora ihoriz.cq� gc Date N( CITY OF CUPEVINO �"ITY OF CUPERTING PERMIT APPLICATION FORMS c, / A.PN #,� fi Date: BAPPLOTHER fi � Bldg Permits . foot Building Address: BBOILERI Boiler <= 100,000 Btu MECHANICAL d_o qfs�, A 1 MECHANICAL BBOILER3 Owner's Name: MECHANICAL Phone #: Boiler > 1M to 1.75 M Btu joswv BBOILER5 Boiler > 1.75M Btu G Contractor: Construction Tax License #: BCONSTAX Contact: BUILDING Cupertino Business License#: Building Permit Info: BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING Bldgr Elect ❑ Z,­--?lijmb Tqech ❑ Job Description: r. BELEC200 Elec Svcs 600V <= 200A Residential ❑ / m�nerci� BUILDING Sq.Ft. Floor Area: Energy Add Multi /Sq.Ft.: BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee Cost of Project: Occupan. Gr p: Type of Construction: Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler <= 100,000 Btu MECHANICAL BBOILER2 Boiler > 100K to 500K Btu MECHANICAL BBOILER3 Boiler > 500K to 1M Btu MECHANICAL BBOILER4 Boiler > 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler > 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax — Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <= 200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING 1 of 3 i S CITY OF CUPEK rINO CITY OF CUPERTINC PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group BMITIGATR Res. Housing Mit Fee BUILDING BMNEWMULTI New Multi -Family Res MECHANICAL BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL BNEWMULTI Multifamily Res ELECTRICAL BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BNUMULTI New Multifamily Res PLUMBING BOVERTIME Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pb1g Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinklerBackflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Vent PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit > 10,000 cfm . MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BREMFURN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > l OK btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BREMNRAPP Rem Non -Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL 2 of 3 alN_"ITY OF CUPERTINC ITY OF PERMIT APPLICATION FORM CUPEVINO Quantity Fee ID Fee Description Fee Group BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT Repair/Alter Heating MECHANICAL BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Signs, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUELDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING BSPECIAL Special Insection BUILDING BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issuance PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Chane BUILDING BMISCELL Building Misc Fees BUILDING 3 of 3 )ceZ J00 W ZZU saW . 0 N )nz a 2 .Mu :0aw O �}a �p0 Jaen za ==o t— °�2 CITY OF CUPERTINO BUILDING DIVISION PERK CONTRACTOR INFORM )N: ` BUILDING ADDRESS: AN KY CONSTRUCTION CO PERMIT NOO 3 0 9 0 0 2 0 20956 HOMESTEAD RD OWNER'S NAME: 2530 BAMB I LN PERMIT ISSUE DATE AFFINITY ENTERPRISE GROUPINC 10124/2003 PHONE: (4 0 8) 2 3 4- 2 6 7 3 SANITARY NO. CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I 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. TENANT IMPROVEMENT License Class Lic. p Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I 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, demolish, or repair any structure $18690 prior to its issuance. also requires the applicant for such permit to Glc a signed statement Sq. Ft. Floor Area Valuation 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 Codc) or 32609061.00 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (5500). ❑ 1, as owner of the property, or my employers with wages as their sole compensation. Required Inspections 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 ns q P 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 - builder will have the burden of proving that he did not build or improve for purpose of sale.). s'F • 1, as owner of the property, am exclusively contracting with licensed contractors to e Contractor's Li- onstruct the project P 70". Business anel Professions Code: -Me �". cense Caw do nota to an owner of property who builds orm v and J who contracts for such projects with a contraeto s licensed pursuant to the Contractor's P License Law. r / >r't- foCo ion. P reaoon ❑ I am exempt under Sec. & C r� Owner C� _ p (G%'Ly/�V RKER'S COMPENSATI D L.ARAT 1 hereby affirm under penally of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Conscnt to self -insure for Workcr's Compcn. 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 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: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is forone hundred dollars (E1011) or less.) I certify that in the performance of the work for which this permit is issued. I shall not 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 Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed mvoked. CONSTRUCTION LENDING AGENCY ti I hereby affirm that there is a construction lending agency lot the performance of the work fur which this permit is issued (Sec. 3097, Civ. C.) Lender's Name Lender's Address I cenify that I have read this application and state that the above information is correct. 1 agree to comply with all city and county ordi..ianees and state laws relating to building construction. and hereby authorize representatives of this city to enter upon the ahove-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 permit. L t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN`r Issued by: Date SOURCE EGUL NS. Re -roofs Type Of Roof rhz (k > Sign ore of Applmani/Contractor Date HAZARDOUS MATERIA SCLO'S Will the applicant or future building occupant store or an c hazardous material as deft ned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? E] Yes �Plo 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 Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as dclined by the Bay Arca Air Quality Management all new materials for inspection. District? Yes XNu ❑ I have read the hazardous materials requirements under Chapter 6.95 of the Califor. nia Health & Safety C°dc, Sections 25505, 25533 and 25534.1 understand that i( the building docs not currently have a tenant, that it is my responsihility to noul'y the occupant of the rcgtn cnLs hiehmustbemcipn.°rtoissuanceofacerrtfic oroecupaney. Signature of Applicant Date All roof coverings to be Class "B" or better owner orizcdagcnt Date m 0% 0 X :E < 0 > 0 u LLJ W z P z 0 a: O (roww (A 0 < CS C) 0 mW 4W W,,> < LU p ONODY > Lq W ef W ly < a- 1 < tmn > 0 Ln Fill—)z LL- a:W Z) Lr) < F- z m of d0"I : C3 Q n- VY4 %CC' 04 bo 0 < 0 m u Z Lu 0 0 u - Sp 0 z 010 z O W Of Z 10 z CN < a Nt)f y n Of < Ln V)CN D OND (.) < a. >V) �n 0 aw UJ trW 0 W Ln z Of L m 7002 PI:92:60 P uPr TJJ 6MP'9NINHVd-OV]iS]WOH9S6Oe\S6MP\JBIUOD @2d0t\:A 0% LU LL- a:W Z) Lr) < 00 z Lo 0 < 0 m u Z Lu 0 0 u - Sp 0 z 010 z DO— W Of Z 10 z CN < a Nt)f n V) co V)CN D OND (.) < a. >V) �n 0 7002 PI:92:60 P uPr TJJ 6MP'9NINHVd-OV]iS]WOH9S6Oe\S6MP\JBIUOD @2d0t\:A