09090015 CITY OF CUPERTINO
BUILDING DIVISION PERMITfl 'TRAflR I� RM7.
IflN.
BUILDING ADDRESS: PERMIT NO.
10431 N DE ANZA BLVD DEVCON CONSTRUCTION IN
SR'S NAME: PERMIT ISSUE DATE
PHONE: A A O. CONTROL NO.
(408) 942-8200
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o O p LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
VZ with Section 7000)of Division 3 of the Business and Professions C2ode,and my license is
'may in full force and effect. — �LJ COM'L TI 1ST&2ND FLR & INTERIOR DEMO(38, 811)CONF
Z License laz Lic.B
c Date d Contractor RMS,OFFCS, FINISHES, FIXTURES& ACCESSBILTY
ARCHITECTS DECLARATION
L) I understand my plans shall be used as public records U PGRADE i L I MTD SITE UPGRADE CONSISTING OF
DW
4 WALKWAYS
Loy Licensed Professional
:1n H OWNER-BUILDER DECLARATION
yL t E I hereby affirm that I am exempt from the Contractor's License Law for the
is C O following reason.(Section 7031.5,Business and Professions Code:Any city or county
.e m E which requires a permit to construct,alter,improve,demolish,or repair any structure
Zy prior in its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or 3 5 0 0 0 0 0
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). 32633114 . 00
❑1,as owner of the property,or my employees with wages az 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 tot 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.).
❑1,as owner of the property,am exclusively conuacting 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 pmjects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec B&P C for this reason
er Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 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.
❑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' Compensation In�s{ur—ance carrier and Politynumb are:
Cartier. U lZ- G r 1 Policy No.: 0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc 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 az to become subject to the Workers'Compensadon
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z 2CONSTRUCTION LENDING AGENCY
HV) I hereby affirm that there is a construction lending agency for the performance of
L�> the work for which this permit is issued(Sec.3097,Civ.Q
Lender's Name
Z
Lender's Address
V I certify that 1 have read this application and state that the above information is
Ll:. correct.l agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. l /
r APPLICANT UNDERSTAND ND WILL COMPLY WITH ALL NON-POINT Issued b):34t�zw Date <
SOUR REG�AO . 6 /)
Re-roofs
Signature of Applicant/Con r Date
H DOUS MATERIA DISCLOSURE Type of I'oof
Will the applicant o utum building occu t store or handle hazardous material
-s defined by the Cupertino unicipal Code, spier 9.12,and the Health and Safety
le,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
Will the applicant or future building occupant use equipment or devices which If a roof s 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 o
I have read the hazardous materials requirements under Chapter 6.95 of dtc Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant it' my responsibility to notify the occupant of the
regmzenta which m be met ar issuancrMoCa Certificale of Occup c'/'
' Signature of Applicant Date
�� 6 /t o
All roof coverings to be Class'J "or better
Owner or authorized agent Dam