06100121 CITY OF CUPERTINO
BUILDING DIVISION PERMIT +G�1"TItAGT�x777.777,77; 7
It}RMATI€ N
PERMIT NO.06100121
BUILDING ADDRESS:
22622 MARIANIST WY
PERMIT ISSUE DATE
OWNER'S NAME:
MARIANIST PROVINCE OF THE S 10/24/2006
SANITARY NO. CONTROL NO.
,)NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
10 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 STRUCTURAL DETAIL CHANGE S
full force and c t.
s ? aen Class Con
Lie.
D `�
Date tractor (-,�jj(
ARCHITECTS DECLARATION
125-, 1 understand my plans shall be used as public records
,a
U.y Licensed Professional
H OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<,�,ii which requires a permit to construct,alter,improve,demolish,or repair any structure 0
Z y prior u)its issuance,also requires the applicant for such permit to file a signed statement
Sq.
Ft.Floor Area
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 ofifl er Occupancy Type
not more than five hundred dollars($500).
0 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 We(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 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.).
0 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 docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
FI I have and will maintain a Certificate of Conscnt to self-insure for Worker'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.
0 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 Workers Compensation Insurance carrier and Policy number arc:
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 of the work for which this permit is issued.I shall not
employ any person in any magna s� to becplpe subjeci to the Workers'Compensadon
Laws of Calif ml yg 1 fC 1 f��IUL
Applicant l`f
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
,J O forthwith 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
(� .7 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U C) I certify that I have read this application and state that the above information is
V.►" correct.I agree to comply with all city and county ordinances and state laws relating to
CVbuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
CL (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
U Z in consequence of the granting of this permit. -POINT2
r"'" APPLICANT UNDERST NDS AND WILL COMPLY WITH ALL NON Issued by: Date —Z�(—v
SOURCE R 10
Re-roofs `— -
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of pl' [/ContractorDatc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill applicant or future building occupant store or handle hazardous material
by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
tion 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yes 1q No
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 Arca Air Quality Management all new materials for inspection.
District?
0 Yes �Q No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requircm tsft must et 'or to issuance of a Certificate of Occupancy. Signature of Applicant Date
l All roof coverings to be Class"B" or better
O cr.6-<&Nd19cnt Date