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08120135Z �z� �raZ t: hu. �,U I y, t- �O Ay K9� —Ze Xi— e59 0z z° car CL A �z UC w F, OU W U hti CITY OF CUPERTINO BUILDING DIVISION PERMIT mgwq���� BUILDING ADDRESS: PERMIT NO. OWNER'S NAME: PERMITMITE DATE PHO RAE31PAR BR A CONTROL NO. 408)942-8200 ARCHn-ECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 aro licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Proressio s Code, and my license is in mu force and effecL T . I ON 2ND & 4TH FLOOR. REMODEL License Class Lie, Date Contractor VGDYV L1Qb15UUf ESTROOM/BREAK/COPY ROOM INCLUDE (M, E, P) ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Conuaetors License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county which mquires a permit to co tsu ict, alter, improve, demolish, or repair any structure ' prior to its issuance, also requites the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for the alleged exemption- Any violation of APN Number Occupancy Type P y yP Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of not more than five hundred dollars (5500). 31622017 ❑ 1, as owner of the property, or my employees with wages as their sole compensaden, .00 will do the work and the structure its not intended or offered for sale (See. 7044, Business Required Inspections and Professions Code: The Contractors 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.). ❑ 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 or property who builds or improves thereon, and who cont acs for such projects with a contractor(s) licensed pursuant to the Connector's License Law. ❑ I am exempt under Sec B & P C for this mason Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker'sCompen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work d for which this permit is issue 2r/I have and will maintain Workers 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 ) surance carrier and and Policy number are: Carrier.zi/�( l GH MfiLfq"PolicyNo.: ii i %iq:.yq CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Ibis section need not be completed if the permit is for one hundred dollars ($100) or less) 1 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 malting this Certificate of Exemption, you should become subject to the Workces Compensation provisions of the Labor Code, you must rarthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCIION 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, Civ. C.) :.enders Namc Lenders Address 1 certify that I 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 building construction, and hereby authorim 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 liabilities,judgmenu, cosu and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLIC UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SO 'Z --z - C>9 Signature of Applicanr/Con t 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)? All roofs shall be inspected to any roofing material being installed. ❑ Ya 0 prior If a roof is installed without first obtaining an inspection, I g s agree to remove P Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? 0 Yes B'No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safcty Conk. Sections 25505, 25533 and 25534.1 understand thaLif We building docs not currently have a tenant. that it is my responsibility to notify the occupant of the requi nu which must bc tpriorlto'ssssuanceofaCerificacofOccupancy. Signature of Applicant Date ass g All roof coverings to be Class `' or better %T Owner Date