07080009 CITY OF CUPERTINO
BUILDING DIVISIGN PERMIT
PERMIT NO.
BUILDJIJ� QR OBSIDIAN CT AAA ELECTRIC 07080009
/ !� PERMIT ISSUE DATE
OWNER'S NAME:
(408) 557-8899
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
ZLICENSED CONTRACTOR'S DECLARATION
,cc Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
z w with Section 7000)of Division 3 of the Business and Profcssi .and my license is REPLACE 15 0 AMP PANEL
H in full fore d cff t. l, 1
,do Z License l J Lic,!t —
Date _Contractors
ARCHITECTS DECLARATION
a< I understand my plans shall be used as public records
tyU
w ti Licensed Professional
1 y OWNER-BUILDER DECLARATION
> 1 herchy affirm that I am exempt from the Contractors License Law for the
:C O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
9 which requires a permit to construct,alter.improve,demolish,or repair any structure
t' prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
Ft. Floor Area
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 S q• $2000 20O0
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Utat 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 Number Occupancy Type
not more than five hundred dollars(5500)• 36218028
❑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 oroffered for sale(Sec.7044,Business Required Inspections
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 improvements are not intended or offered forage.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 Contractors 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 Contractors
License Law.
❑1 am exempt under Sec, B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have 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 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 Workers 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 for one hundred dollars($100)
or less.)
I certify that in the performance 5r which this permit is issued.I shall not
employ any person in a nc me subject to the Workers'Compensation
Laws of California
Applicant `
NOTICE TO Ai!ft1eAJb9krTfar making this Certificate of Exemption,you should
become subject to the orker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
E-4 rA I hereby affirm that there is a convection lending agency for the performance of
Px> the work for which this permit is issued(Sec.3097,Civ.C.)
aQ Lendcr's Name
z Lcnder's Address
U Q 1 certify that I have read this application and state that the above information is
IS, — correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction•and hereby authorise representatives of this city to enter upon the
W
ahove-mentioned property for inspection purposes.
(We)agree to sayY¢¢indc nify and keep harmless the City of Cupertino against
to liabilities,judgments,cdsrs�art expenses wg of this t.hich may in any way accrue ag tsald City
U Z in consequence of the gr06 Date
APPLICANT UbjPS SAN ILL COMPLY WI N-POINT Issued b�:
SOURCE PEG r
Re-roofs
Signature o Appli nt/con 'r
trac
HAZARDOUS M TERIALS DISCLOSURE Dare Type of Roof
Will the applicant or future buil ing 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)? All roof: shall be inspected prior to any roofing material being installed.
❑Yes _'OtJo
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r materials for inspection.
District?
❑Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Secudfis 25P5.25533 and 25534.1 undcrstan at if the building
does not currently have a tenant,t17�i' is my responsibility to notify c Deese t of Use
requirements which must be r to issuance of a Cenifica}ygf Signator;of Applicant Date
All roof coverings to be Class"B' or better
Owner or aptho4ed gent Date