07030002 CITY OF CUPERTINO
BUILDING DIVISION PERMITT �
BUILDV6 ESS: PERMIT NO.
S� N WOLFE RD CHARLES PANKOW BUILDERS LTD 07030002
0111NER'S NAME: PERMIT ISSUE DATE
CUPERTINO SQUARE LLC 2101 WEBSTER ST, STE 1500 05/07/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
REVISION: ADDING CRASH BLDG ELECT PLUMB MECH
100 LICENSED CONTRACTOR'S DECLARATION BARR;�^ T m JfvF_fb escnption
%u 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
j z U with Section 700W)of Division 3 of the Business and Professions Code,and my license is
a in full force and effect
j ? License Class Lic.p
yF in Date Contractor
ui ARCHrmcT-s DECLARATION
Ca I understand my plans shall be used as public records
)aU
U.y Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p o 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
Z y prior to its issuance.also requires the applicant for such permit to file a signed statement
L= that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q.Ft.Floor Area Valuation
F$ (commencing with Section 70DO)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 APN Number Occupancy Type
not more 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 for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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,
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 k-'--_,_1_aTPmject
of the property.am exclusively contracting with licensed contractors to
(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 contras s)licensed pursuant to the Contractor's
License Law.
❑I am exem du Sec, B&P C for 7th' rc n
verDate
U7
WORKER'S COMPENSATION DECLARATION
;'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 Compcn-
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 arc:
Cartier. Policy No.:
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 certify that in the performance of the work for which this permit is issued,1 shall not
employ any pc any manner so as to bee a subject o pcnsation
Laws of Calif ' .D tc
Applicant
NOTICE PPLICANT:If,a making this Certificate of Exemption,you should
become sdbject 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
�~t►�-+ 1 hereby affirm that there is a construction lending agency for the performance of
iY the work for which this permit is issued(See.3097,Civ.C.)
Wfs.A Lender's Name
a z Lender's Address
U C) 1 certify that I have read this application and state that the above information is
Lr~ correct.I agree to comply with all city and county ordinances and state laws relating to
U U building construction,and hereby authorise representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hfn liabilities,judgments,costs and expenses which may in anyway accrue against said City
U Z in consequence of the granting of this permit. Date
APPLIC UNDERSTANDS AND WL COMPLY WITH ALL NON-POINT Issued by:
SOU EGULATI S
!`7 Re-roofs
Si tureo Applicant/Contractor areType Of Roof
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
'de,section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes XNo
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 m:iterials for inspection.
District?
Cl 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 thc building
docs not currently have a tenant,that it is my nsibility to notify the occupant of the
require hmusL arto� of a Certificate of Occupancy. Signature )f Applicant Date
All roof coverings to be Class"13"or better
Ow or authorized agent D