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CITY OF CUPERTINO
BUILDING DIVISION PERMIT!!MC!AVrEr%
Bu1Lgf6r�, T"A'OLLINGER RD
60131
OWNER'S NAME:ITLSSITEPACIFIC
RIM PK LLC
/18/2008
PHONE:
SANITARY NO. CONTROL NO.
(925) 468-0115
A RCHI'TEC'C/ENGI NEF.R:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby affirm that n; I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Prolicasions Cade, and my license is
SET CONDUIT FOR FUTURE CELLULAR FACLTY INSTLTN
inf�q and `ff"` Le-M
W/TRNCHNG&PAD AS NEEDED, PROJC IS
Dam t43 ;EU-'�contmanr�®
ARCHITECTS DEC TI N
j�D&UNOCCPD .
I understand my plans shall be used as public records
WK FOR PRTN OF PROD ON PR IV PRO PTY ONLY- TEMP
Licensed Professional
OWNER -BUILDER DECLARATION
I bcrcby aRrm that I am exempt from the Conunctoes License Law for the
following rmwn (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to connruet, alter, improve, demollst. or repair any structure
prior to its issuance, also requires the applicant for such permit to ilk a signed nalomen,
that he is licensed pursuant to the provWona of the Contractues License Law (Chapter er 9
Sq, Ft. Floor Area Valuation
m (comenting with Section 7000) of Division 3 of the Business and Professions Code) or
$110 0 0
that he is esempt therefrom and the basis for the alleged exemption. Any viol ion of
�T�,7�I,,..r,
3 6 9 3 4 0 5 2 Am ber
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penahy of
not more than rive hundred dollars (S500).
,' L"i'tC M
❑ L as owner of the property, or my employees with wages as their sole emnpesssadon,
e
Required Inspections
will do the work, and the structure isnot intended orotferedfor ask (See.7044,Business
and Professions Code: The Contractor's License Law does aot apply to an sawn of
Q p
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements am not intended or offered for ale 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.).
❑ L as owner of the property, am exclusively contracting with licensed conuactors to
corumnct the project (See 704d, Business and Professions Coda) The Contractor's li-
cense Law does not apply to an owner of property who builds or improve thereon, and.
who contacts for such projects with a contrana{s) licensed pursuant to the Comr&=r's
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby air= under penalty of perjury one of the following declarations
❑ I have and will maintain a Certif1am of Consent to self-insum for Worleces Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I 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
'
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. ,aV'�NSTG,<J �'-b,Poliry Na; �7 t.. C'y,
'D L)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less)
I cenify that in the performance of the work for which this permit is issued I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
.
Laws of CalifomfL Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenifiate of Exemption, you should
become subject to the Workees Compensation provisions of the Labor Code, you must
-
forthwith comply with such provisions or this permit shall be doomed revoked
I
CONSTRUCTION LENDWG AGENCY
I hereby alTirm than there is rt construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lender's Name
,
L.entices Address
j I certify that 1 have mad this application and state that the above information is
'
collect I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize reprarmarives of this City to enter upon the
atwvc-mcntioned property for inspection purposes.
( (We) agree to ave. indemnify and keep harmless the City of Cupertino against
j fiabilities,judgments, cogs and expenses which may in any way accrue against said City
in consequence of the granting of this pcnniL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
FkLWCE REGULATIONS.
Re -roofs
Type Of Roof /
i
Signikure ofApplirsHAZAtractor Dam
RDOUS MATERIALS DISCLOSURE
HAZARDOUS
Will the applicant or future building occupant store or handle hazardous material
as defuted by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section 2ss3z(a)7
❑Yes 9No
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 deOned by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes XNo
I have mad the hum-dous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safety Code, Sections 25505.25533and 25534.1undcratandthat lfthe building
does not currently have a tenant, that It is my responsibility 10 notify the occupant of the
""nLt which must be met prior w iss°ran" °f' Certifi"m of parMy'
Signature of Applicant Date
S
All roof coverings to be Class'j' or better
Dam .
owner t,raatnorirrA agent