07080273 CIT�' OF CUPERTINO
BUILDING DIVISION PERMIT ���T�+����� �����'�'`� �
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PERMIT NO.
BUiLO � r ���� ess STEVENS CREEK BLVD TBD T� BE DETERMINED 07080273 .
OW IYER'S NAMH: FERMIT LSSUE DATE
BAL JINER DHAHJAL 10/01/2007
NE: SANITARY NO. CONTROI. NO.
BUILDINC PERMITINFO
ARC HI7'ECT/ENGiNEER:
BLDC ELECT PLUMB MECH
� � � �
i p o LICENSED CONTRACTOR oECr..neanox 7ob Description
; v� [ hereby aCfirm that I am licensed under provisions oC Chap�cr 9(commencing
; withSection700U)ofDivision3ofUuBusinessandPcofessionsCode TI COD'II�IERICAL RETAIL SPACE — INCLUDE ELECTRICAL�
� a a in full force and effe
��z LicenscClass �'� �•# � MECHANICAL� PLUMBING
; F � Datc / - �' Contractor ,
a ARCHifECI'S DECLARATION
i a a I undcrstanJ my plans shall t�c useJ as pu6lic rccarcis
)aU
° o. y Licensed Prufessionai
� y j OWNER-BUILDER DECLARATION
>' 1 hcrcby alTirm Ihat I am cxcmpt Crom ihc Contractors Liccnsc Law for t6c
� p O following rcasoa (Secuon 7031.5, Busincss and Profcssions Codc: Any city or rnunty
�,°, �i which rcquires a pertnit to conswct, alter, improvc, dcmoli.eh, or repair any stn�cturc
�,Z } prior in its issuancc, also requircs ihc applican� for such pertnit to filc a signcd sta�mcn�
• < �hat hc is licensed putsuant to thc provisioas of the Contractor's Liccnse Law (Chaptcr 9 5q. Ft. Floor Area $ g 5 0 0 0 Valuation
4 F$ (commcncing wi�h Sccuon �000) o( Division 3 nf thc Busincss nnd Professinns Codc) or
��... that he is ezempt Nctctrom md We basis for Ihe allegcd eumpdon. Any violatiun o(
Section 7031.5 by arry applicant for a peanit subjecu the applicant to a civil penalty of NlliT1I�Ci Oeeupaney Type
not more than five hundred dollars (5500). 3 5 7 17 Q 12 ��
❑ I, u owner oC ttie prop�ty. ar my cmployces with wagu az eheir solc compensation,
willdothcwork.andthes�ruaureisnotintendedorofferedforsale(Sec.7044.Busi�ess Re uired Ins ections
and Professions Code: The Conuactors License Law dors not apply to an owner of 9 P
propeny who builds or improves thercan, and who does such work himulCor ttwugd 6is
own employccs, providcd that such improvements are not in�endeA or oCtered for sak. If.
however, the building or impmvement is sold within one year of completion, �he owner-
buitder will have the burden o[ proving Uiat he did no� build ar improve for purpose of
salc.).
Q 1, as awnor oC the property, am exclusively conuaaing with Iicensed rnnvxtors W
conscruct the projett (Sec. 7044. Business and Pro[essions Cade:) The Convacmrs Li-
cense Law docs not apply �o an owner of propeny who builds or improves �he�eon, and ,
who wnuac�s for such projecu wi�h a coNractar(s) licensed pursuant to the Cantractors
License Law.
Q I am ucmpt undu Sec. . B dc P C for �his rcasai
Owner �a�
WORKERS COMPENSAT[ON DECLARATION
I hemby aftirm under peoalty o[ pery'ury one of the (allowing declarauon�
❑ 1 hsre and will mainttin a CertiGpte of Consent �o ulf-insure for Workcrs Compen-
sarian, u provided for 6y Section 3700 of the Cabor Cade. Cor �he pedormancc ot ihe
work for whic6 �his permit is issucd.
❑ I havc and will maimain Workcr's CompensaUon Insurance, az rcyuired by Scction
3700 of the Labor Code. fw the performance of �he work for which this pecmit is issued.
My Worke�s Compensation Insurancc camer and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completcJ i[ the permii is for onc hundccd dollars (S1a0)
or Icss.) '
1 cectify th¢t in �hc performancc of ihc work for which Ihis permit is iscucd, 1 shall na
omploy any person in any w�ecg�p�,subiecUo ihe Workcrs' Compensalion
Laws of Califomia. D � G�
Applican�
NOTICE TO A a i �s ertificatc of F�cemptian, you should
become subjcct Wo 's Compcnsation provisions of thc Labor Codc, you mus[ '
� O fortNwith comp ith suc pmvisions or this pccrni� shall bc dccmcd revokcd.
Z '"' CONSfRUCf10N LENDING AGENCY
F r �-�. I hcrehy affirm that thcre is a conswction Icnding agcncy (or thc per(ortnancc uf _
(Y., � ihc work Cur which ihis permi� is issucd (Scc. 3097, Civ. CJ
W� Q Lcndcr's Namc '
a z L.cnde�s Addrcss
U 0 1 certify �ha� I havc rcad this applieauon and sta�e �hat �hc above infortnauun is
w � cortec� 1 agree ta comply wiW all city and county onfinances and sute laws relating �o
� U building conswction, and hcreby authoriie rcpresentativcs of ihis city to cnicr upon ihc
� � abovc-mcntioncd property (or inspccuon purpoxs.
(We) agrce to save, indemni(y and kecp harmless �he Ciiy of Cupert�no against
�� liabilitiu, judgmcn�s, costs and expenses which may in any way accruc against said Cry
V z in consu{uence o[ thc granting oC �his permi� Date
►�+ APPLICANT UNDERSTANDS AND W1L[. COMPLY WITH ALL NON-POINI' Issued by .
SOURCE REGULATIONS.
Re-roofs
Signawro of Applicant/Contracmr Da�
HAZARDOUS MATERIALS D[SCLOSURE Type of R.00f
w II �hc applicant or futwc building occupant storc or handlc harardout matcrial
as dcfincd by lhe Cupertino Municipal Codc. Chapicr 9.I2. and thc Hcat�h and Safcty
c«� Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs ❑ No
wll thc applicant or futurc building occupant usc cquipmcnt or Jcviccs which
If a roof is ins[alled without first obtaining an inspection, I agree to remove -
emii harardnus air conuminants u Jcfincd by ihe Bay Arca Air Quality Managcmcnt all new rr aterials for inspection.
as����
❑ Ycs ❑ Nu
1 havc rcad the ha�arCcws mauerials requircmcrts undcr Chap�cr 6.95 of thc Califor-
nia Hcalth & Safct Codc, Sectiant 25505. 25533 and 25534.1 undcrs�ind �haz i! Ux building � �� ,� ���
docs not currc a tcnan4 �� it is my responsibility m noafy �hc occupant oC �hc
rcyuircm ust bc met prior 'ssuarKC of a Ccnificaic of OccupancY. DBte
�
�.) Sig e of pplicant
pa � . All roof coverings to be Class "B" or better
or ri�cd agcnt