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CITY OF CiJP DIVISION 7-,��n�
BUILDING DIVISION PL'
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BUILDING ADDRESS:
XL CONSTRUCTION
PERMIT NO
03080089
OWNER'S NAME:
1500 BERGER
DR
PERMIT ISSUE DATE
STAR—ONE BANK
D811912003
PHONE:
(408)271-2425
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) or Division 3 of th�siness and Professions Code, and my license is
imm�f rc andcffca. �L4 �[Q
TENANT IMPROVEMENT '
License re.N •
Date / d " Conti to lY�, Le2 N=a°fya•' a "^
ARCHITECTS D AR�fION
�µrfder an plans shall be used as public records
Licensed bfpssional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor'sLicense Law for the
following reason. (Section 7031.5, 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 forsuch permit to rile a signed statement
that he is licensed pursuantlo the provisions of the Contractor's License Law (Chapter 9
Sq. Ft.. Floor
Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
32610059.00
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 ($500).
❑ I• as owner of the property, or my employees with wages as their sole compensation,
0 1 —
d Inspections
will do the work• and the structure isnot intended oroffered forsalc(Sec.7044,Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
10 2
PIERS l?
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,
103 —
iJFER
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 build or improve for purpose of
104 —
REBAR
sale.).
105 —
ANCHOR BOLTS
❑ 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-
10 6 -
SEWER & WATER
cense Law does net apply to an owner of property who builds or improves thereon. and .
202 —
UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
203 —
UNDERFLOOR MECHANICAL
❑ 1 am exempt under Sec. , B & P C for this reason
204 —
UNDERFLOOR FRAME
Owner Dale
205 —
UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
301 —
ROUGH PLUMBING .
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
302 —
TUB & OR SHOWER
sation, as provided for by Section 3700 or the Labor Code, for the performance of the
303 —
ROUGH ME CHAN I CAL
work for which this permit is issued.
304 —
ROUGH ELECTRICAL
[:11 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.
3 05 —
FRAME
MyWorker's Compensation Insurance carrier and Policy number are: t�
a •er: �U tom'' C'�n Amer,0, t'Iicy N ` W Q� ��p�l
306—
307 —
HOEDOWNS
INSULATION
CERTIFICATE OF EXEMPTIO M WORKERS'
COMPENSATION INSAANCE
308 —
SHEETROCK
(This section need not be completed ifthe permit is for one hundred dollars($100)
309 —
EXTERIOR LATH
tri less.)
310 —
INTERIOR LATH
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'Compcnsation
311 —
SCRATCH COAT .
Laws of California. Date
Applicant
313 —
501 —
ROOF NAIL
F I NAL ELECTRICAL ENERGY
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 previsions or this permit shall be deemed revoked.
502 — ,
F I NAL PLUMBING ENERGY
' CONSTRUCTION LENDING AGENCY
503 —
FINAL MECHANICAL ENERGY
1 hereby affirm that there is a construction lending agency ror the performance of
504 —
FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lcndcrs Name
5 0 5 —
r
FINAL ELECTRICAL r.
Lendcr''sAddress
506 —
GAS TEST '
I certify that I have read this application and state that the above information is
507 —
FINAL PLUMBING
' correct. I agree to comply with all city and county ordinances and state laws relating to
' building construction, and hereby authorize representatives of this city to enter upon the
FIN ME CHAN CAL
? above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
1 liabilities. judgmc�o s and expenses which may in any way accrue against said City
O 9
5
F IN
A NG
in consequence d the Taming of this permit.
APPLICANi�UND STANDS AND WILL COMPLY WITH A NON -POINT
Issued by:5
C WORKS Date
SOURCE EGU}
Ll5
Re -roofs
Sig t Applicant/Contractor ate r
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building uccupam store or handle ha'iardous material
as defined by the Cupertino Municipal,Codc. Chapter 9.12, and the Health and Safety
cede, se] Yes WN. Section 25532(a)?
❑
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for
inspection.
District?
❑Yes XNo
I have read the hazardous materials requircmcnis under Chapter 6.95 of the Califor.
niaHealth&SajetSCrydc,Sec6ons25505,25533and25534.Iundccs that ifthc building
i.
Joys not cogently Advo a tenant, that it is my responsibility to notify th. •cup Itthe
cquircm is wh' must be met prior to issuance of a Certificate of cu ane
Signature of Applicant Date
All roof coverings to be Class "B" or better
wn rer thorizcdagcnt Dale