09010083BUILDING DIVISION PERNHT
PERMIT NO.
10100
OWNER'S NAME:
ARCHTTECT/FNGINEEX'
O p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
U with Section 7000) of Division 3 of cite Business and Professions Code, and my license is
y in full force and affect.
j License Class Lie. N
+w-,p Date Contractor
ARCHffECTS DECLARATION
1 understand my pions shall be used as public records
in ri
t a Licensed Professional
5 G OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
is G O following reason- (Section 7031.5. Business and Professions Code: Any city or county
K $_ 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
< that he is licensed pursuant to the provisions of the Contactors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the B usineu and Professions Code) or
y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (MMM).
❑ L as owner of the property, or my employers 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 Contractors License Law does not apply to an owner of
property who builds or improves themon, and who does such work himself or through his
own employers, provided that such improvements ate not intended or offered for sale. If,
however, the building or improvement la 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
SRI".
L as owner of the property. am exclusively contracting with licensed contactors to
construct the project (Sec- 70". Business and Professions Code:) The Contractors u-
ecme 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 Contractors
License Law-
❑ I am exempt e , B & P C for reason
OwDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of peaty 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
❑ 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 isated
My Workers Compensation Insurance carrier and Policy number are_
Carrier, Policy No.:
CERTIFICATE OP IXEMFnON FROM WORKERS'
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 ivaed. I shall not
—ploy any person in any m pa as to becomta'SBject to the Worker' Compensator
Laws of California.
ApplicantOL
NOTICE TO APPLICANT: if, e r mil ng rs 'irate of Exemption, you should
become subject to the Workers Compensation provisions of the Isbor Codc, you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
z — CONSTRUCTION LENDING AGENCY
(� ►�.e 1 hereby affirm that then: is a construction lending agency for the performance of
CG the work for which this permit is issued (Sec. 3097, Civ. C.)
a0 Lenders Name
►7 Z Lenders Address
ri 0 I certify that 1 have read this application and state that the above information Is
i>+ correct. 1 agree to comply with all city and county ordinances and state paws relating to
a building construction, and hereby authorim representatives of this city to enter upon the
> a above -mentioned property for inspection purpose.&
(We) agree to save, indemnify and keep harmless the City of Cupertino against
to Ilabilities,Judgments. costs and expenses which may in any way accrue against said City
U 7 in consequence of the granting of this permiL
r� APPLICANT UN TANDS AfD)WILL COMPLY WITH ALL NON -POINT
SOURCES.
d 1
Signature n r to
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? CCC'''
❑Yes Llano
Will the applicant of ffuore building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes No
I have read the materials requirements under Chapter 6.95 of the Califor-
nia Health &SafelyCodc, Secdo s 25505.25533 ara125534,1 wWcrmnd that if the building
don not curmnl4 a trnan. tOUlr ulny raponMbilily to notify the occupant of the
rcquimmcplSw�(pnor to issuance of a Certifa:ae of OcLydanryl
408)255-9994
PERMIT ISSUE DATE
Job Description
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
COMM'L TI INCLD HANDICAPPED ACCESSBLTY,UPGRDS,
NEW
HVAC& NEW FIRE SPRNKLRS (2577 SQ)
Sq. Ft. Floor Area
32631019.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Type
Date 66
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
all new materials for inspection.
Signature of Applicant Date
. All roof coverings to be Class'%" or better
Owner