07090052 CITY OF CUPERTINO � ' y�,�
BUILDING DIVISION PERMIT �*�����Q� �����"�`
,>. <: ..:. ; _ : ..: .:. . :
_, . ;
BUiLDING ADDRESS: PERMIT NO.
20488 STEVENS CREEK #2050 SCOTT ARCHITECTURAL 07090052 �
0W NER'S NAME: Vt� rn i�. PERMTT LSSUE DATE
STEVENS CREEK COMMERCIAL 1275 N DUTTON AVE
SANITARY NO. CONTROL NO.
VE:
(707)545-4519
BUtLDWG PERM11'INFO
ARCHITECC/ENGINEER:
BLDG ELECT PLUMB MECH
� � � �
i p p LICENSED CON7RACTOR'S DECLARAT[ON JOU DCSCTIptlOil
:�`^ ! hcrcby afGrm �hat 1 am licensed undcr provisions of Chapicr 9(commcncing
; z� wiih Sccuon 70oU) of Divisian 3 of ihe Busincu � P J r} � i�� o d c. and my liccnsc is I N S TA L L I NG �' I�'iN .
� a a �n full Coree an eft �
j� z Licensc C�1�s � L�. # 7 1 � J
� p pa� U ' Conuacar
� ARCHITECI'S DECLARA ON
7 a a l undcrstand my plans shall bc uscd as public reconts
)aU
' u. y Licensed Prufcssional
� � a OWNER-BUILDER DECLARATION
°�� 1 hcrchy a1Trm Ihal 1 am excmpl fmm ihc Contractors Liecnsc Law far Ihc
� p O following rcason. (Scction 7031.5, Business and Profcssions Ca1c: Any city or couniy
�°, � which rcquires a permit to conswc4 alur, improvc, dcmolish, ar cepair any stn�ctucc
° Z y prior w its istuancc. also rcquims Uic applicant for such pertnit to filc a signed slatcment , F[. FIOOI' AI'eS Valuation
�_< that hc is liccnscd pucsuanl lo thc pmvisions o[ thc Contractar's Licxnsc Law (Chaptcr 9 �q
u ti$ (commcncing wi�h Section 7000) of Division 3 of thc Business and Profcssions Code) ur � 1 0 � � �
y �., ihat he is exempt theccfrom and the batis [or the allcged eumption. Any violazion o[
Secrion 7031.5 by any applicant for a permit subjccu the applicant w a civil pwlty ot p Number Occupancy Type
not morc [han fivc hundrcd dollars (5500). 3 6 9 � 1 � 6 6.��
❑[. as owncr of U�e prope�tY• or my employces with wages as the'v solc eompecwdon.
willdothewock.and�hes�cuaweisnotintendedorolleredforsa�(Sec. Required Inspeetions
and Professions Cade: The Conuuar's License Law does nat apply to an owner of
propeny who builds ar improves tMercon, and who daes such work himsel( or Uuoagh Ais
own emptayces. provided that such improvementt are not imended or o[Ceced for sale. If,
however, the building or improvcment is sold within onc year of completion. �he owner-
builder will have the burden o[ proving Ihat he did nat build or improve Cor parpose of
salc.).
❑ 1, u owner o[ the property, am aeclusively conuuting wi�h licenxd conaactas to
consuuct the projea (Sec. 7044. Businas and ProCessions Code:) The Con�s Li-
cense Law dors not apply to an ownu of propeny who 6uilds or impmves WeROn. �nd ,
who conuac�s [or such projects with a rnnuactoKs) liansed pursuant m �he Contneeors
License Law.
❑ I am aempt undu Sec. , B dc P C far ihis �esson
Owner Datc _ , _
WORKER'S COMPENSATfON DECLARATION
I hcrcby aRicm under penalty of perjury one of the following dataratianx
�,_J I hsre and will maintain a CertiGcate af Conscnt to self-insure (ar Worlrc�s Canpen-
sation, as provided for by Secuan 3700 of the [abor Code, for the pedormance o[ the
work for which Ihis pertnit is issucd.
0 I havc and will maintain Worker's Compensation Insurance, u mquired by Scction ,
3700 oC the Labor Code. for the performanee at the worlc for which �6is pe�mit u issued
My Worke�s C naa�iOn �ca�e camu and Policy num6��� ��^
Cartier: � � Poliry No.: y f
CERTIFICATE OF EMPI70N PROM WORKIItS'
COMPENSATION INSURANCE
(fhis sectian need rrot bc complctcd i( the pem�it is fw onc hunNcd dol�acs (5100)
or Icss.)
i cenify that in thc performancc af Ihc work fw which Ihis pertnit is issucd. 1 shall not �
emplay any person in any manner so az to become subject to Uie Worlcers' ComQe�atian
Laws of Cali(omia Datc
Appticant
IVOTICE 7'O APPC.ICAM: If, af�cr making this Ccrti[icatc of F�ccmpGon, you shouW
become subjcct to thc Workcr's Canpensation provisions of Nc La6ar Codc, you muu
� O forchwit6 comply with such provisions or this permi� sha0 6c dccmcd mrokcd.
z ""' CONStRUCTfON LENDING AGENCY
(. ►�-. 1 hemby afiirm U�at there is a conswction Iending agency Ior �he perCormancc o( .
p�., � Uic work far which ihis permit is issucd (Scc. 309"/, Civ. C.)
W� Q L.endcr's Namc �
� � l.cnder's Address
V � � cenity �hai I have read this application and sutc ihat the abavc infom�auun is
w � corrcct. 1 agree �o comply with all city and county oreiinances and state laws relaang W
� U building conswction, and hcrcby authori�e represcntativcs of lhis city to cntcr u�n thc
� W aM1ovc-mcntiuncd property for inspcction purposes.
a (Wc) agree save, indcm�i(y and kecp harmless ihc Ci�y of Cuperano agtinst
�� liabiliuu, judg �s, s and expenses which may in any way accruc against said City
U,Z in conxquenc of the ��g or �n�: a���. Date ��� � l `��
�+ APPUCANT ND S ANDS AND WILI. COMPLY WITH ALL ON � Issued by.
SOURCE RE O . � �
Re-roofs _i� ---
Signaturc of A li ontrxtor � T of R oof
HAZARDOUS MATERIALS DISCLOSURE YP
Will Ihc plicant or futurc building occupant storc or handlc hxrardous ma�crial
az dcfincd 6y the Cupenino Municipal Cadc. Chaptcr 9.12, and �he Health and Safety
Cafc, OYo o All roofs shall be inspected prior to any roofing material being installed.
Will �hc applicant or fuwre building occupant usc eyuipmenl or �kwices which
If a roof is installed without first obtaining an inspection, I agree to remove •
emit haratdous air con�aminan�s u dcfincd by the Bay Arca Air Quali�y Managcmcn� all new rr aterials for inspection.
District?
Q Ycs Nu
Ihav �cadtheha�arCwsmaterialsrcquircmcn�sundcrChap�cr6.45aC�heCa�Yor
nia Hca S ty C , Scaions 25505. 25533 and Z5534.1 undcrstand thu if ihe building
docs n curtcni ve tcnan4 �az il is my responsi6iliry to noul'y Uu t of Ux
reyuire ts w h m Dc mel prior u� issuancc oCa Ccnit atc o Signature of Applicant Date
� pa � . All roof coverings to be Class "B' or better
Owncr o aul ' ed agcnl