07050105 CITY OF CUPERTINO
BUILDING DIVISION PERMIT TQRMW A.
PERMIT NO.
BUILD 9q��EssMARIANI ST WAY TBD TO BE DETERMINED 07050105
I'S NAME: PERMIT ISSUE DATE
AARIANIST PROVINCE OF THE 05/25/2007
PHONET L' SANITARY NO. CONTROL NO.
ABUILDING PERMIT INFO
RCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
i p p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REV I S I NI 3 AC C E S SAB I L I TY PATH OF TRAVEL AND PARKING
t<a in full force and effect.
iz License Class Lica STALLS. ORIG #05090218—NO NEW PERMIT. NIBBI BROS
p Date Contractor
ARCHITECTS DECLARATION HAS BL f28662 .
i a< I understand my plans shall he used as public records
raU
U.�- Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for tbe
3 00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
V which requires a permit to construct,alter,improve,demolish,or repair any structure
z r prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
c=� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 .rq O
c t•-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)w
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 Number Occupancy Type
not more than five hundred dollars(5500). 3422905 1
❑I,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 Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of 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.
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 does not apply to an owner of property who builds or improves thereon.and.
who contracts for such projec with a contractor(s)licensed pursuant m the Contractor's
License Law.
[l I am exempt under B&P C for this reason
Date V ZS d
W SATION 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 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 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 Workees Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMP 70N 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 per a of c work for which this permit is issued,1 shall not
employ any person i r to become subject to the Workers'Compensation
Laws of Cali i
Applicant
NOTICE TO APPLICANT:If,aKcr making 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" CONSTRUCTION LENDING AGENCY
►�-� I hereby affirm that there is a construction lending agency for the performance of
fl! the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
0 Lender's Address
V 0 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
UU building construction.and hereby authorize representatives 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
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of ming of this permit. Date
"- APPLICANT U ANS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE EG
V2_ Re-roofs
Signature of Applicant/Co ctor Date T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
'cfrncd by the Cupertino Munici al Code.Chapter 9.12,and the Health and Safety
Section 25532(a)? All roofs,hall be inspected prior to any roofing material being installed.
C]Yes o
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 materials for inspection.
District?
❑Yes V IN.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& ct ode,Sections 25505,25533 and 25534.1 understand that if the building
does not cu Ll a tenant.that it is my responsibility to notify the occupant of the
rcyuire be met prior to issuance of a Certificate ofOcup Occupancy Signature A Applicant Date
�� All roof coverings to be Class"B"or better
Owner ori, agent