09060012 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT � �A � �� T � r
BUILDING ADDRESS: PERMIT NO.
10555 MARY AVE CITY O: CUPERTINO 09060012
OWNER'S NAME: PERMIT ISSUE DATE
_rTTV np CJJPERTINn
ONE: ARffAiRO 0 Q 9 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION
U): I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
in full force and effect MV WAL-., 35" TO EXPAND SML OFC RM, RELOCT & ADD
D UJ Z_ License
=" enscClasa
Date Contractor ELECr RELOCT R/A VENT, RELOCT SPRNKLR
F r� ARCHITECTS DECLARATION
a�C< 1 understand my plans shall be used as public records
�yU
n.y Licensed Professional
L.
y
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
i iz O following reason.(Section 7031.5,Business and Professions Code:Any city or county
k m which requires a permit to construct,alter,improve,demolish,or repair any structure
Z prior to 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
y 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 $100
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). 32606052 . 01
❑1,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(See.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)//
7u owner of the property,am exclusively contracting with licensed contractors to
. 'ruct 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 contractor's
License Law.
❑1 am exempt under SecB&P C fo this ason
Owner \ Date 6 Z J z
WORK COMPENSATION DECLARATION
1 hereby afli
W=ORK
of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
,ation,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 am:
Carrier. 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 cenify that in the performance of the work for which this permit i ' ued,I shall not
employ any person in any manner6to to Wmc subject to the 'Compensation
Laws of California.Date 7
Applicant
NOTICE TO APPLICANT:if,after making this Cc sate of Exemption,you should
become subject to the Worker's Compensation pruAsiorts of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z . CONSTRUCTION LENDING AGENCY
H1 hereby affirm that there is a construction lending agency for the performance of
(Yi the work for which this permit is issued(Sec.3097,Civ.C.)
WGI.A Lender's Name
►7
Lcndees Address
U I certify that 1 have read this application and state that the above information is
LL" correct.I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
U above-mentioned properly for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
U'Z in consequence of the granting of this permit.
APPLICANTNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATIONS. '
Z A Re-roofs
Signature of Applican Con torDate
H OUS MATERIALS DISCLOSURE Type of Loof
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(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or future building occupant use equipment or devices which If a roof i s installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.9Softhc Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 undsratan'd that if the building
does not currently have a tenant,that it' y responsibility'lo notify the occupant of the
requirements whit must be met pri issuancc.of9 certificate of Oc ey Signature of Applicant Date
Owner or authorized agent �� Z
Date All roof coverings to be Class'�W'or better