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08120077 CITY OF CUPERTINO BUILDING DIVISION PERMIT O PERMIT NO. BUILDING ADDRESS: 10900 N BLANEY AVE BLDQ, 2 4 TBD — TO BE DE PERMIT ISSUE DATE OWNIT'S NAME: SXNhA CONTROL NO. ...ONE: BUILDING PERMIT INFO ARCHPIECTIENGINEER: BLDG ELECT PLUMB MECH a 0 0 0 ed a p C LICENSED CONTRACTOR'S DECLARATION Job Description V C I hereby affirm that I am licensed under provisions of Chapter 9(commencing m withfull Section7 ofDivision3ofsheBusinessand PProfessionnssCode.and mylicense is REPLC 5 BROKN A/C UNITS & 2 EVAPRTV C00LERS (SWAMP n in _:)w�z License ass Contractor COOLERS) *JOHNSON CONTROLS HAD BUS LIC #22775 t Date ARCHTIECT'S DECLARA N I understand my plans shall be used as public tecordt �yU O y Licensed Professional OWNER-BUILDER DECLARATION .I- I hereby affirm that I am exempt from ft Contractors Lfccnse Law for the %00 following reason.(Section 7031.5,Business and Professions Code:Any city or county Pi which requires a permit to constmt.alter,improve,demolish,or repair any structure _ prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Y r (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or $92000 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(5500). 31603045 .B2-4-5 ❑I.as owner of the property,or my employees with wages as their solo 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 docs 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. 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 contractors to construct the project(Sec.7044.Business and Professions Code:)The Contractor's li- cense 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. ❑1 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.- 0 eclarations:❑1 have and will maintain a Certificate of Consent to self-insure for Workers 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 Workers Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My wor s Compeosa. Insurance carrier and Policy number am: Cartier. Gam Polity No.:'�S `� 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,l 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 Workces Compensation provisions of the Labor Code.you must `j. forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONSTRUCTION LENDING AGENCY Fr rrn-r I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) W A Lenders Name ]2 [.enders Address U 0 I certify that I have read this application and state that the above information is LL hr correct I agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorim representatives of this city to enter upon the W above-mentioned property for inspection purposes. CL (We)agree to save,indemnify and keep harmless the City of Cupertino against E" liabilities,judgments.costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit F-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date © �- SOURCE CATIONS. 1 Re-roofs — Signature pplrcan�—OUSMATERIALS Da T of Roof DISCLOSURE ypewill the applit store or handle hrrardohts 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. r-]Yes RNo ff� 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 haardous air conurn' ants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes No I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safety C7agent 0 25505,25533 and 25534.1 undcrsund that if the building docs Thor chhrrendy h at it is my res nsibilit W no fy the occupant of the requirements which rinr once er a c oroecmpanry. Signature of Applicant Date All roof coverings to be Class'J�"or better Owner or autharixcDate