09010057:00
to
IUZg
V
A.
u.t;
t0
res
too
S$�
.z�
p
CITY OF CUPERTINO
PERMIT
e �;q§ •fir, :,,��,,u� �,� s w, Fr�*S,�c3';'r�+�t
BUILDING DIVISION
.. .RP - -
BUILDING ADDRESS:
- -
PERMIT NO.
OWNER'S NAME:
FWAIT LSSUE DATE
PHO
S 2609 CONTROL NO.
ARCHI'IEC (ENGINE I.:
BUILDING PERMIT INFO
DEMO ON IST & 2ND FLOOR
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I w licensed under provisions or Chapter 9 (commenting
with Section 70D0) of DivWon 3 of the Business and Professioyns Cod!and my license is
in full force and effect C U
1
A�RCHITECI-S DECLAI A710N
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to consuacm 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 ContractoA License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the B usiness and Professions Code) or
that he is exempt thrrefrwn and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
P cy Type
Section 70313 by any applicant for a permit subject/ the applicant to a civil penalty of
not more than five hundred dollars (S500).
L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
wiR do the work, and the structure is not intended or offered for sale (Ser. 7044. Business
and Professions Code: The Contracmrs 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.).
❑ L as owner of the property. are exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The Contracl L.1 -
cense Law does 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 contractors
License Law.
❑ I am exempt under Sec , B k P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under ptmaily 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 Elie Labor Code, for the performance of the
work for which this p"mil 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 Worker's Compensation Insurance �' �nand Pplicynombu are:
Grier.\ c'(CI� r4artal(;a✓�`PoBcyL�: C Z�179�s
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
Chit section need not be completed If six permit It for one hundred dollars (SI00)
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 Workere Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Codc, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (sec 3097, Ch. C)
Lender's Name
'
[.entices Address
I certify that I have read this application and state that the above information is
correct. I agree to epmply with all city and county ordinances and safe laws relating o
building consuucAnri, and hereby authorize representatives of this city to enter upon the
ahbva•pm 0ricd prripgrty for inspection purposes.
•fWi) agfce W gave indemnify and keep harmless the City of Cupertino against
filhiptie . jn¢Mequ egsts and expenses which may in any way acauc against said City
In. cc uftlie Awning of this permit.
AT'PL !q UNDfiRSTANDS AND WILL COMPLY WITH ALL NON -POINT
/7
Issued by: Date
."1
S UTAT N, f
/Cl- p^
r
� �
r�
Re -roofs
Type of Roof
grtatq)pAr.A icatrUComractor Date
. HAZARDOUS MATERIALS DISCLOSURE
VIN pre applicant or future building occupant sore or handle hazardous material
/
as doflltod. by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
ceOr, fl 25532(a)7 No
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
w(lF 4rc applicant or fuwre building occupant use equipment or devices which
erpil haaardous air contaminants as defmcd by the Bay Area Air Quality Management
all new materials for inspection.
Disiricl4
. No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
.
aja•HW Lfi tk SafciyCode, Sections 25505.25533 and 25534. I understand that if Ute building
docs pot cgr{cntiy have a tenant. that it is my responsibility to notify the occupant of the
M1�Ls wit met prior roiss°anee Oracl:rdrical F of CaZpancy,
j
Signature of Applicant Date
O
ititnorvcd '
All roof coverings to be Class '%" or better
rack W agent Dao