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CITY OF CUPERTINO�
BUILDING DIVISION PERMIT
TQRTS F.I?MACIE�iti
BUILD ESS:
PERMIT NO.
��D�� STEVENS CREEK BLVD
TBD - TO BE DETERMINED
09060005
OWNER'S NAME:
PERMITLSUEDATE
:
SA I&ARY N 6. CONTROL NO.
ARC HtT EGT/ENGiNEML,
BUILI)ING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I bcreby affirm that 1 am licensed under provisions of Chapter (commencing
Ikon 3 of the Business and Prolcssiona Code, and my license is
force
COMM ' L T I (19 5 7 SQ) NEW INTERIOR PART ' S NEW
iwith n full and effect.
, RSTRM
License class
LAYOUT, EXT A/C UNIT REMAINS, NO STRUCTRL OR
Date ntndor
ARCHITECTS DECLARATION
RE-RF; OPTOMETRY OFC
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or County
which requires a permit to construct. alter. improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Conractor's Licarm Law (alapucr 9
Sq. Ft. Floor Area
Valuation
(commenting with Section 70D0) of Division 3 of the Business and Professions Code) or
$ 4 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Oecu ane e
p yTyp
Section 703i-5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars300). (5
35908022T,
❑ 1, as owner of the property, or my employees with wages at their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered forsale (Sec.7044, Business
and ProfessionCode: The CoThe Conuaclor•s Licerm Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
oven employees, Provided that such improvements are not intended or offered for ak. If,
however, the building or Improvement is sold within one year of completion, the owner -
builder will have the burden of proving that be did not build or improve for purpose of
Safe-).
&L as owner of the property, am exclusively contracting with licensed contractma to
construct Lite project (See. 7044. Business and Professions Code:) The Contractor's Ll-
ecru 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 Sec- . B & P C for
sre.noonn
rtthis
Owner Date
i
WORKERS COMPENSATION DECLARATION
under pensity, of perjury one of the following declarations
❑ 1 have and will maintain a C=Ufiate of Consent to self -insure for Workcr'a 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 Irtmr moc carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhtt section need not be completed if the permit is for one hundred dollars (3100)
or kss.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any maancr so a toyec�qqtte subject to the Werktrs' Coens mpation
ws Laof California. Date %f_'LC'/ties
Applicant
-
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 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.)
Undoes Name
,
Lender's Address
I certify that I have read this application and state that the above Information is
correct i agree to comply with III City and county ordlnerces and state Is" relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for Inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabiliues,judgments,costs and e.xpcnaes which may In any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date /Zip
SOURCE REGULATIONS.
Re -roofs
Type of
the appliant or future building oavpant store or handle hazardous material
r
as dented by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes 'kAo
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 commntfntnts as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yeso
i have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Cade, Savona 25505.25533 and 25334.1 understand thn if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior
Applicant Date
All roof coverings to be Class 'AQ ' or better
ate -
Owner or authorimd agent
_