01050053 CIBUILDI c DrvEBIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10101 N DE ANZA BLVD ASSOC:;I A 1 E'u C"(INT RAC FORS COR401050053
OWNER'S NAME: APPLICATION SUB DATE
FIDELITY FEDERAL BANK 840 Tllf?`7' t;: l 05/03/2001
PHONE: SANITARY NO. CONTROL NO.
4089-1 •71.400
M m Z ARCHITECT/ENGINEER: BUILDING PERMIT INFO
w BLDG ELECT-.- PL M M H
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Z�ti in� affirm
CONTRACTOR'S DECLARATION Job Description
I hereby arm that 1 am licensed under provisions of Chapter 9(commencing
t7 w.,W with Section 7000)of Division 3 of the Business and Professions Code,and my license
Y�`4 is in full force and effect L1C# 'Cr
T'EMPORARY 30-DAY PERMIT EXPIRES 0E,/03
.,a License Clas
Date Contractor O t 5
w a ARCHITECT'S DECLARATION
N y I understand my plans shall he used as public records
wr
W a q O Licensed Professional
OWNER-BUILDER DECLARATION
Lu- I hereby affirm that I am exempt from the Contractor's License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or county
Owhich requires a permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement z•I
°• that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Floor Ar^ �r1• Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code) �,..., - tan v Ck CO O
or that he is exempt therefrom and the basis for the alleged exemption.Any violation 1,
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars($500). ��aj (�/ T pOccupancy Type
❑I,as owner of the property,or my employees with wages as their sole compensation, Contra cts '•' ���, ?+�te
will do the work,and the structure is not intended or offered for sale(Sec.7044, rG
Business and Professions Code:The Contractor's License Law does not apply to an Spon • UjS101%t••1ouired Inspections
owner of property Who builds or improves thereon,and who does such work himself 0 sions a� � �• OUNDAT I ON
or through his own employees.provided that such improvements are not intended or /� 15
offered for sale. w however,the building or improvement n sold within one year of COtnp1et@d
completion,the owner-builder will have the burden of proving that he did not build or M G t{1�
improve for purpose of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to POO* 4 4 _. R 'i'1�.,�fJ _
construct the project(Sec.7044,Business and Professions Code:)The Contractor's !J // •7rnh/_`J !,,
License Law does not apply to an owner of property who builds or improves thereon, rr BOLTS /JLr//
and who contracts for such projects with a contractor(s)licensed pursuant to the From p C/
Contractors License Law. IOF, -- SEWEP. C�•��--11
❑I am exempt under Sec. ,B&P C for this reason VOR PLUMBING
e '''
Owner Date 51%nature
WORKER'S COMPENSATION DECLARATION � 0 --" UrdDERF ITICAL.
I hereby affirm under penalty of perjury one of the following declarations: Deisa _OO R FRAME
10I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the ' -r ROUGH PLUMBING
performance of the work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 302 '"' TUB & OR SjHOI-lE R
3700 of the Labor Code,for the performance of the work for which this permit is 303 - ROUGH MECHANICAL_
issued.MyCWorkeer s Compensation Insurance carrier and Policy number aree:�
Carrier:J�}*7C F"-&- Policy No.: J^7 '01 V 10 q 304 Rl-n
LJOPH ELECTRICAL
CERTIFICATION OF EXEMPTION FROM WORKERS' 305 -- FRAME
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars 306 - 1-101-DOWNS
($100)or less.) 30r7 - INSULATION
I certify that in the performance of the work for which this permit is issued,1 308 --- SHEE T ROCf i
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of California.Date 309 - EXTERIOR LATH
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should 310 -" INTERIOR LATH
Z become subject to the Workers Compensation provisions of the Labor Code,you must
0 O forthwith comply with such provisions or this permit shall be deemed revoked. 311 - SCRATCH COAT
r�
(~ � CONSTRUCTION LENDING AGENCY ,y 13 -�• ROOF
It1A I L,
aI hereby affirm that there is a construction lending agency for the performance 501 FINAL ELECTRICAL I GAL ENE RG Y-
W of the work for which this permit is issued(Sec.3097,Civ.C.)
ZLender's Name Lender's Address 50i? -- F I NAL PLUMBING ENERGY
V 0 I certify that 1 have read this application and state that the above information is 50,E - FINAL MECHANICAL ENERGY
0�+ F., correct.I agree to comply with all city and county ordinances and state laws relating 504 -... F I I''1AL BUILDING ENERGY
V to building construction,and hereby authorize representatives of this city to enter upon
W the above-mentioned property for inspection purposes. 5�� - FINAL ELECTRICAL
y Gy (We)agree to save,indemnify and keep harmless the City of Cupertino against TEST
►r V] liabilities,judgments,costs and expenses which may in any way accrue against said ,r'l rti � - GAS
V Z City in consequence of the granting of this permit. rti G
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. Issued by: 507 - FINAL PLUMBING Date
Signature of Applicant/Contractor Date Re-roofs WaMECHANICAL
HAZARDOUS MATERIALS DISCLOSURE 509 - FINAL. GRADE
Will the applicant or future building occupant store or handle hazardous material Type of Roof
as defined by the Cupertino unicipal Code,Chapter 9.12,and the Health and Safety L ._, t
Code,Section 25532(a)? 5 10 FINAL. 1-LANK I II1L:i
❑Yes No All roofs shall b&bs'peetedFp(tNALarFy( l 46df-mboMMing 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 contamin nts as defined by the Bay Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
El Yes No all non-point source regulations.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently have a tenant,that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of -
Occu a X310 Signature of Applicant Date Owner or authorized agent Date All roof coverings to be Class"B„Or better
OFFICE