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CITY OF CUPERTINO
BUILDING DIVISION PERMIT it~;~~~~~i~~I__~~,~~l~{
BUILDING ADDRESS: PERMIT NO.
19333 VALLCO PARKWAY BLDG C DPR CONSTRUCTION INC' nQnhfH)I')"i
OWNER'S NAME: PERMIT ISSUE DATIl
71DDT.~
PHONE:
T7IT(' 1 AC,1l 'TDrn~D""T,", ,",TT~ n r '" " '''''''nsXN1l'AJ{YNO. ~~~ CONTROL NO.
(650)474-1450
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG
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ELECT
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PWMB
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MECH
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LICENSED COflfl'RACTOR'S DECLARATION
I hereby affinn LhaJ I am licensed under provisions of Chapler 9 (commencing Job Description
with Section 7000) of Division 3 of lhc Business and Professions Code. and my license is
in full fOlt:e and effeel ! Sq-Cj 'J'-( b COMM'L DEMO FOR COMM'L TI OF BLDG C, UNTIERGRND LicenseCJ~ Lie. ~
DalC/3tft ConlraclOr PeR cPt'\J SfRyC-r70iJ UTILTY WORK, (115,000SQ)I ; ARCHf1ECTSDECLARATION
I undemand my plans shall Ix: used as public records
Licensed ProCessional
OWNER-BUILDER DECLARATION
I hereby affirm thou 1 am c;cmpl frum the ConlnClors License Law for lhc
rallowing reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a penni I (0 conslrUcL aller, improve. dcmoli!=:h, or repair any Slruclun:
prior to its issuancc. al50 requires lhe applicanl for such permiL to file a signed SLalCmenl
Ihal he is licensed pursuant La the provisions of the ConLractor's License Law (ChaplCr9 Sq. Ft. Floor Area Valuation
(commcncing with Section 7(00) of Division 3 of the Business IlI1d Professions Code) Dr
thaI he is exempt thelt:from and the basis for Ibe aJleged exempUon. Any violaUon of 5125000
SecUon 703l.S by any applicant for a permit subjec ... the applicant 10 a civil penally of APNNumber Occupancy Type not more than Ii"" hundred dollazs (S500). 31620075.BLDGCo I, as owner of the property, or my employees with wag"" as their sole compensaUon,
win do the worle. and the slnlclure is oat inteoded or alTered for sale (Sec. 70404, Bu&incss
and Professions Code:: The Conua:tor's License Law dot.! oat apply 10 an owner of Required Inspections
property who builds or improves lhcn:on, and who does sueh work himself or lhrough his
Own employees. provided lhal such improvements are not inlendcd or offered for sale. If.
however. the building or impro~mcnt is sold within one year of completion. me owncr
builder will have the burden of proving that he did not build or impro"" for purpose of
sale.).
o I. as owner of the propcny. am exclusively contracting with licensed contractors LO
eonslnlct Ibc: projeet (See. 7044. BllSincss and Professions Code:) The COOll1\etor's li
cense Law does not apply 10 an owner of propeny who builds or improves thereon. and .
who conll1\CU for such project.< with a conll1\ctor(s) Iiceosed pu"","nllO the CDnll1\etor's
License Law. o I am exempt uoder Sec. , B &. PC for this It:ason
Owner Dall:
WORKER'S COMPENSATION DECLARATION
I helt:by affirm uoder penally of petjury one of Ihe foJlowiog declaraUoos:
o I h."" Dod will maiotaio a CertificolC of ConseOI10 self-insure for Worker's Compen
sation. as provided for by Section 3700 of the Labor Code, for the performaoce of the
work for which this permit is issued.
o I have and wiJl maiolain W",kcr's Compensation Insuraoce. as required by SeCtiDo
3700 of the Labor Code:. for the performance of the work for which this permil is issued.
My Worker's Compensation Insunnce carrier and Policy number are:
Carrier. W/I...U S tJ;;,zptAN82<fI1pOliey No.: WGj'jCJoh21
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seclion oced not Ix: eomplelCd iflhe permil is forooe hundlt:d doJlazs (SIOO)
or less.)
( certify th.t in the performaoce of Ibe work for which this permit is issued. I shall 001
employ any person in any manner so as 10 bc:come subjeellO the Wor1r:en' Compensation
Laws of California. Dall:
AppUcaot
NOTICE TO APPUCANT: If. after makio& this CenilicalC of Exemptioo. you should
become subject 1O the WOrkcr's Compensation provisions of thc Labor Code. you mlL~t
forthwith comply wilh such provisions or this pcr:nil shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby amrm that there is ~ constructinn lending agency for lhc pcrfonnancc of
Ibe work for which this pennit Is issued (See. 3097. Civ. C.)
Lender's Name
Lender's Addn:.u
tIl
J ccnify that I have read 1his application and stale that the above infonnauun is
CCKTCCll agree to comply with all city and county ordinances and slale laws n:laling to
building conSlruction. and hereby authori7.e representatives of lhis eity to enlCr \lpon the
above-mentioned properlY for inspection purposes.
(We) agree 10 save, indcmnify and keep harmless Ibc: Cily of Cupertioo againsl
tIl liabilities, judgments. casu and e.xpc:nscs which may in any way acerue against said City
in consequence of the grantiog of Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT -Date t~;7zfrIssuoo by; CJf<!kJCiiJshJ
SOUR~NS. 'A 6o l lcJ ] '0
Re-roofs ~' ...SignalUleoA ~dJ DalC Type of RoofHAZARDOUS MATERJALS DISCLOSURE
Will the applieanl or futun: buildlog occupant Slolt: or haodle haz.anfous material
as defined by Ibe Cupenioo Muoicipal Code. ChaplCr 9.11. aod the Health and Safely
Code, Seetioo 15531(a)1 All roofs shall be inspected prior to any roofing material being installed. G]-No
If a roof is installed without first obtaining an inspection, I agree to remove
DY""
Will the applicant or futun: building occupant usc equipment or devices which
emil huzardous air conLaminanU as defincd by the Bay Area Air QualiLy Man2.Gement all new materials for inspection.
District?
DYes ilfol"D
I havc It:ad Ibc: h37.ardous maltnals requirement.< under ChaplCr6.95 of the Califor
oil Health&. SafelYCodc. Sections 15505.15533 and 15534. IllOde=d thai if the building
cJocs not currcntJy have a lenant., Out h is my rcsponsibilily to notify Ihe OCC\lpam of lhc c#IA-?Ic ,1&1
reqUire??: m:>Ix::;/~ issuane.: of a Certificate of O;:cu£(;I /,/{ Signature of Applic'ant Date
All roof coverings to be Class ''ft.'' or betterIOwner or aut6ori7.cd agent DalC