06120171 CITY OF CUPERTII�O
BUILDING DIVISION PERMITNFt}RMATI
PERMIT NO.
BUILDING ADDRESS:
22622 MARIANIST WY MARIANIST PROVINCE OF THE 06120171
OWNER'S NAME: PERMIT LSSUE DATE
MARIANIST PROVINCE OF THE 03/06/2007
SANITARY NO. CONTROL NO.
BUILDING PERMrr INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
i p p LICENSED CONTRACTOR'S DECLARATION Job Description
v1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Zwith Section 7000)of Division 3 of the Business and Professions Code,and my license is REV I S I 0 LST: ELECTRICAL DRAWING & DIESEL GENERATOR
in full force and affect.
j Z License Class Lic.N D/'Y/� Jew"%��"'✓ ��G��C.��( U
+E n Dam Contractor
Lu ARCHITECTS DECLARATION
I understand my plans shall he used az public records
>yU
U.l'- Licensed Professional
: < OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
por� 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
-Z y prior u)its issuance,also requires the applicant for such permit to file a signed statement Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $2937603
r F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
u 5 E that he is exempt therefrom and the basis for the alleged exemption.Any violation of N
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 34229051
`` p Number Occupancy Type
not more than five hundred dollars($500).
0 1,as owner of the property,or my employees with wages as their sale 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 docs 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
I,as owner of the property,am exclusively contraMing with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
ccnse 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 theContractor's
License Law-
C3 --
I am exempt under .@ dS:P Cfar this rgazon. ... -
Owner w
COMPENSATION DECLARA170Ns/ .
I hereby affirm under penalty of perjury one of the following-declarations,
0 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.
0 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 carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars($100)
or Icss.)
I 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 Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after mating 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
1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(See.3097,Civ.C.)
W A Lender's Name
Ci. Z Lender's Address
U Q 1 certify that I have read this application and state that the above information is
LL i correct.I agree to comply with all city and county ordinances and state laws relating to
rJ J building construction.and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
P4 (We)agree to save,indemnify and keep harmless the City of Cupertino against
,•"y t4 liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERST D WILL COMPLY WITH ALL NON-POINT Issued b't:
S4
SOURCE REGULATI ` Q
Re-roofs
Signature of Applican for am
HAZARDOUS MATERIALS DISCLOSURE Type of'Zoof
Will the applicant or future building occupant store or handle hazardous material
az 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.
0 Yes I(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 az defined by the Bay Area Air Quality Management all new I naterials for inspection.
District?
0 Yes Nu
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
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements whit t met prior to issuance of a Certificate of Occupanry. Slgnatur°of Applicant Date
0 All roof coverings to be Class"B or better
Owner or aul t m