02090188N
y
N
CITY OF CUPERTINO
BUILDING DIVISION PEPHT
INFO:
BuIL210011110FsTOWN CENTER LN # 190
TDN QUALITY CONSTRUCTION
PERMIT NCO 2090188
2114 SENTER ROAD
APPLICATlorgyq" 2002
PHONE:
,(408)998-0980
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
TI --DENTAL
OF JVLJ,1�_scription
with Section 7000) of Division 3 of the Business and Prorfirsiolode, andp*4kensc is
in full force
and effect. 9
License as, Lic.
D.W_4�1 o Wh—Contractor
DECLAR&ION
J.-la-nd7my-
I plans
lans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
$80000
following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which 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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
than five hundred dollars
1 UAPMN4ffiNIN
L)A*I'i UN Occupancy Type
not more ($500).
102
PIERS
C] 1. as owner of the property, or my employees 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 Contractor's License Law does not apply to an owner of
1: E) 3
104
UPER
REBAR Required Inspections
property who builds or improves thereon, and who doessuch work himself or through his
own employees, provided that such improvements are not intended or offered for see. If,
105
ANCHOR BOLTS
however, the building or improvement is sold within one year of completion, the owner-
106
SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
202
UNDERFLOOR PLUMBING
rl 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 of property who builds or improves thereon. and
204
UNDERFLOOR FRAME
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
205
UNDERFLOOR INSULATION
C] , am exempt under Sec. B & P C for this reason
301
ROUGH PLUMBING
Owner Date
302
TUB & OR SHOWER
WORKER'S COMPENSATION DECLARATION
303
ROUGH MECHANICAL
I hereby affirm under penalty of perjury one of the following declarations:
304
ROUGH ELECTRICAL
0 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
3 05
FRAME
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
306
HOLDOWNS
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
307
- INSULATION
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
308
- SHEETROCK
Carrier: Policy No.:
309
- EXTERIOR LATH
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
310
- INTERIOR LATH
(Thissection need nOLbe completed ifthe permit is forone hundred dollars($100)
311
- SCRATCH COAT
or less.)
313
- ROOF NAIL
I certify that in the performance of the work for which this permit is issued, I shall not
501
- FINAL ELECTRICAL ENERGY
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
502
503
- FINAL PLUMBING ENERGY
- FINAL MECHANICAL ENERGY
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
504
- FINAL BUILDING ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
505
- FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
506
- GAS TEST
the work for which this permit is issued (See. 3097, Civ. C.)
Lend r Name
c
507
508
- FINAL PLUMBING
- FINAL MECHANICAL
r:s
Ltnde s Address
I certify that I have read this application and state that the above information is
509
- FINAL GRADE
correct. I agree to comply with all city and county ordinances and slate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
5)
FINAL PLANNING
above-mentioned property for inspection purposes.
14
FIN
(We) agree to Save, indemnify and keep harmless the City of Cupertino against
VWgRKS
liabilities, judgments, costs and expenses which may in any way accrue against said City
MPUBLI
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
Date
SOURCE WS.
Re -roofs
Type of Roof
G;1
Signature oTApplicant/Conuactcle' V Date
HAZARDOUS MATERIALS DISCLOSURE
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 prior to any roofing material being installed.
[] Yes ONo
If a roof is 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?
F1 Yes ONo
I have rethe hazardous materials requirements under Chapter 6.95 ofthc Califor-
nia 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
requiremenrX,us, be metror to issuance, of a Certificate I cy.
!
2hL
Signature of Applicant Date