07070167BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
ARCHITECTIENGINEER:
LICENSED CONTRACTOR'S DECfARAI IUN
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code. and my license is
t ° in full force and effect �.j
Licensc C Lk. N e.�
EA
Date I undcrARCH ctor
NConaA
sta n An s 3 p
-'U
�- Licensed.....- . ......
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
j 00C following reason. (Section 7031.5. Business and Professions Code: Any city or county
li which requires a permit to construct, alter, improve, demolish, or repair any structure
c y prior to its issuance, also requires the applicant for such permit to file a signed statement
a that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
$ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
C — 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 mono than five hundred dollars (S500).
1, as owner of the property, or my employes 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
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended oroffeted for sale. If.
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
sale.
1, as owner of the property, am exclusively contracting with licensed connectors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
ccnse 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 under Sec . B & P C for this reason
�— Owner Dale
WORKER'S COMPENSATION DECLARATION
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
0 0
Job Description
REVISION TO T.I.- MISC CHANGES TO CASEWORK &
LIGHTING, E/M/P, STRUCTURAL, LOADING DOCK.
SECURITY GRILLE NOT BEING DONE -DELETED FROM
Sq. Ft. Floor Area
Num
32619020.00
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sadon, as provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
I I have and will maintain Workers Compensation Insurance, as mquited by Section
37 p of the Labor Code. for the performance of the work for which this permit is Issued.
My Worker oyper(�tost career and Policy number ate: �
Cartier ��!/ /C /C Policy No;: Av�4
EZF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secdon need not be completed If the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.) shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you mew
forthwith comply with such provisions or this peanil shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
r ram. 1 hereby alf rm that there is p construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
1 Q Lenders Name
Z Lenders Address
Q 1 certify that 1 have read this application and state that the above Information is
-+ correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorirs representatives of this city to enter upon the
W shove -mentioned property for inspection purposes
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
(n liabilities, judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
APPLICANT UND ANDS AND WILL COMPLY WITH zue_
N-POINT
SOURCEREGU !
d
signature of pplicant/Contnctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or bandle hazardous material
as definod by dhc Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, section 25532(a)?
❑ Yes �0 No
Will the applicant or future building occupant use equipment or dcvk= which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
0 Yes �No
I have read die hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building
does riot currently It tenant that it is nsponsibilily to notify the occupant of die
requirements wh' must be met ' r to of a Certificate of
Owner or authorized agent Date—r
Issued by:
Re -roofs
Type of Roof
Required Inspections
on
Occupancy Type
Date /(41/ '/(.,
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.
nt Date T—
All roof coverings to be Class "B" or better