07010134 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Ct1 'T'�� TI'1R I�1I+ lR1YIiTI�N.
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
1\R T AT T r U n?L+TTm
SAND HILL PROPERTY MANAGEMENT 10100 N TANTAU AVE 01/22/2007
JNE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
=Z with Section 70(X))of Division 3 of the Business and Professions Code,and my license is ILLUMINATED DATED SIGN "VER I GY" CHANNEL LETTER &
y in full force and _
ori
n z License Class 1 � r n Z 3 MONUME.JT
a Date Conuactor
ARCHITECTS DECLARATION
a U I understand my plans shall be used as public records
a
4 G H Licensed Professional
n r n OWNER-BUILDER DECLARATION
a X 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
y p o following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
n Z} prior to its issuance,also requires the applicant for such permit to file a signed statement
=G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor AreaValuation
$8400(commencing with Section 7000)of Division 3 of the Business and Professions Code)or 8 4 0 0
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy T e
net more than five hundred dollars(M). 31619 01 i 1 P Y Yp
❑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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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.).
❑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 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 Contractor's
License Law.
❑1 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:
❑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.
❑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 comer d P icy number am:
Cartier. _ S �oliev
CERTIFICATE OF EXEMPTION FROM WOkRERS'
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,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
F-r r'-• I hereby affirm that there is a construction lending agency for the performance of
Qui the work for which this permit is issued(Sec.3097,Civ.C.)
WCL.Q Lender's Name
r7 z L.endees Address
U 0 1 certify that I have read this application and state that the above information is
L>. correct.I agree to comply with all city and county ordinances and stale laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
H liabilities,judgments,costs and expenses which may in any way accrue against said City
U'Z in consequcgceof the- rating of this permit.
APPLICANT UND TA AND WILL CO PLY WITH NON-POINT Issued by: Date
AloluR REG ON
1120407- Re-roofs C7
\_ t Btuo ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or future building 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)?
[:]Yes 329110Allroofs shall be inspected prior to any roofing material being installed.
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 rr aterials for inspection.
District?
❑Yes No
1
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Sactions 25505,25533 and 25534.1 un 'land thatif the building
docs not currently have a rant that it is my responsibility to otil'y the occupant of the
rtQiiiremc wJtmustbe el poor tgiss "upas Signature of Applicant Date
O Tor uthorired agent ate
All roof coverings to be Class"B"or better