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CITY OF CUPERTINO —:
BUILDING DIVISION PER MI
BUILDING ADDRESS: / Lese
PERMIT NO. 05030122
:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licclxacd under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force andcfreeL
CONDO-3 STORY (2, 682' LIVING)
License class Lien
Da�
Date Contractor
NEW ADDR WILL BE ASSIGN ON WILDFLOWER WAY
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors 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 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
$ 3 218 4 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
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 contracting 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 projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 ham and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the tabor 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 Workers Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (i 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 as to become subject to the Workers' Compensation
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 Lahr 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.)
Lender's Name
,
Lender's Address
1 certify that 1 have read this application and state that the above information is
" correct. 1 agree to comply with all city and county ordinances and state laws relating to
r building construction, and hereby authorize representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
" (We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any wayaccruc againstsaid City
in consequence of the granting of this permit.'
" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs —
'Type of Roof
Signature of Applicant/Contraclor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore orhandic hayardousmaterial
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code. Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ❑ No
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 contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection. ,
District?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that 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 to issuance of a Certificate of occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorized agent Date
CITY OF
CUPEI�TINO
City of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: (408) 777-3228
FAX: (408) 777-3333
BUILDING DEPARTMENT
OFFICIAL NOTIFICATION OF ADDRESS CHANGE
TO: All Agencies
FROM: City of Cupertino
DATE: April 6, 2006
RE: Address Change (APN #366-19-071)
Please note the following address change: 1375 S. DeAnza Blvd has been subdivided.
The commercial bldg 1375 S DeAnza will remain. The added 2nd story will be assigned
1377 & 1379 S DeAnza Blvd. The six condos will be on Wildflower Way. Their
addresses will be 7375, 7373, 7371, 7369, 7367 and 7365 Wildflower Way. Please update
your records accordingly.
The new address will take effect thirty days from the date of this letter. If you have any
questions, please call me at (408) 777-3246.
Sincerely,
9
.f°
Susan Winslow
Administrative clerk
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�LAWRENCE E. STONE —ASSESSOR
Codmtrd map Id eae ml pxD6� 001y.
COmpied under R k T. Code, See 327.
Etf-U. Roll Y. 2005-2008
Cupertino
13