07050225 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
+CON.T. TORI U AT 4J�1•
PERMIT NO.
BUIU�II`jp�C2ggES$ANDLEY DR SAN JOSE CONSTRUCTION 07050225
l U `� Li PERMIT ISSUE DATE
OWNER'S NAME:
PBS ASSOCIATES 1210 COLEMAN AVE 05 07
SANITARYYNO. CONTROL NO.
jNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: INTERIOR .DEMO, CARPET AND BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION WALL Job Description
u(= 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
.Z�d with Section 70(X0)of Division 3 of the Business and Professions Code,and my license is
>> infull force and effect. Z_C) 3�.
? License 1 s Lic•ff
' p
Date o Contractor IkW '�Sr. �•-+���J�7��v
►w ARCHITECTS DECLARATION
i aa
a I understand my plans shall he used as public records
)yU
toy Licensed Professional
a OWNER-BUILDER DECLARATION
'r 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
Cp O following reason.(Section 7(X31.5,Business and Professions Code:Any city or county
�0.ff which requires a permit to construct,alter,improve,demolish,or repair any structure
"H prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
2 F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 AI'N Number Occupancy Type
not mote than five hundred dollars($500).
❑I,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 forsale(Sec.7044,Business Required Inspections
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 or offered for sale.If.
i
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.).
❑I,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 docs 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 Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Insursncc cam��rp P nut �7
Cartier. �V bl.•C �I-i Polo.: lam_
CERTIFICATE OF EXEMPTION FROM W RKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I 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 Workcrs'Compensation
Laws of California.Date
Applicant
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z " CONSTRUCTION LENDING AGENCY
[�►�. I hereby affirm that there is a construction tending agency for the performance of
the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
az Lender's Address
U 0 ('certify that 1 have read this application and state that the above information is
t>,h correct.I agree to comply with all city and county ordinances and state laws relating to
Q U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
Ia. (We)agree to save,indemnify and keep harmless the City of Cupertino against
HV) liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date
►� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 5
SOURCL'R GIONS.
'tom Re-roofs —�
Signature of ApplicanVContr actor Dam Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE yP
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)? l All roofs shall be inspected prior to any roofing material being installed.
E]Yes
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 contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
1 have read the 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 have a tenant that it is my responsibility to notify the occupant of the
requip7 which mtut be met prior to issuance of a Certificate of Occupancy. Signature of A ppl icant Date
l ° All roof coverings to be Class"B"or better
Owner or authorized agent Dam