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CITY OF CUPERTINO
DIVISION PERMIT
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BUILDING
BUILDING ADDRESS:
PERMIT NO.
10500 N DE ANZA BLVD F R 1
DEVCON CONSTRUCTION
^WNER'S NAME:
PERMIT ISSUE DATE
T f690
PHONE —
GT AR DR
A CONTROL NO.
(408)942-8200
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
HLIXi ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
INTERI C R DEMO OF 1ST AND 2ND FLOOR. 86,000 SQ FT
in full force and effect.
License o
DaContractor
Date Contractor
Da
FINISHES, PARTITIONS, CEILING,
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
License Law 9
that he is licensed pursuant to the provisions of the Contractor's (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$145000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (s500).
3 1 6 2 2 01 7 . FLR 1
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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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
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 bold or improve for purpose of
sale.).
ItI, 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 La
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❑ 1. t under Sec B& P C r this reason
y, Date
WORKER'S CO PENSATION DEC TION
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'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.
❑ 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 are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 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 making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, 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, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
correct. 1 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
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liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence or the granting of this permit.
NDE A DS D WILL COMPLY WITH ALL NON -POINT
" APPL1�11EOVLLA
Issued by:(&W Date
SOURTI NS
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Re -roofs
Signatu APPli Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Loof
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
',,dc, Section 25532(a)?
❑ Yes IQl No
All roofs shall be inspected prior to any roofing material being installed.
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If a roof i s installed without first obtaining an inspection, I agree to remove
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?
❑Yes �No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia &Safety Cade, Sections 25�d 25534.1 understand that if the building
docs of rrenlly ha a t, til R my res ns' ility to notify the occupant of the
requ remc is which m met ' r w tssuanco rtrh�ate of ores .
Signature of Applicant Date
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All roof coverings to be Class 'A" or better
Own o uthorizcd agent I Date