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CITY OF CUPERTINO
7777
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BUILDING DIVISIONPEi RlYl��lT
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BUILDING ADDRESS:
PERMIT NO.
06030057
10255 LOCKWOOD DR
OWNER'S NAME:
PERMIT ISSUE DATE
0 12 2006
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
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with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
S FDWL 3 7 7 5 ' / GARAGE 6 8 9 '
License Class Lic. 0
, .
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 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
8 4 8 0 9 2
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 Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Businessand Professions Code) or
,
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
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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 employers with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Code: The ContractorLicense Law LiceLaw does not apply to an owner of
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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.).
I 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors 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.
❑ I am exempt under S B& P C f r th' reason
nerCv tl/:172 ^i Date
ORK 'S CeIVIPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain aCettificmc of Consent to self -insure for Workers Compen-
sation, 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 Workers 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 are:
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 certify that in the performance of the ork for hi this permit is issued, I shall not
employ any person in any manner is t to the Workers' Compensaton
Laws of calirnmi
Applican
NOTIC aft 'ng this Cenr tcate of Exemption, you should
become subject 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
I hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (Sec. 3097. Civ. C.)
'
Lenders Name
,
Lender's Address
1 certify that I have mad this application and state that the shove information is
'
• correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorizt representatives of this city to enter upon the
ahove-mentioned property (or inspection purposes -
(We) agree to save, indemnify and keep harmless the City of Cupertino against
o) liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSJP�NDS AND COMPLY WITH ALL NON -POINT
�RC-E-REGUL�Y'T(S 0";
Issued by: Date •+ /���C
Re -roofs
Type of Roof
SiWuic ofApplicant/Contractor D
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stom or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
c«le, section 25532(a)7 0 Yu -( tawNo
All roofs shall be inspected prior to any roofing material being installed.
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?
0 Yes kp4Nu
I have read the hazardous materials requirements under Chaprer6.95 of die Califor-
nia Hcalth & Safety Code, Sections 25505.25533 and 25534. [understand tha if die building
does not currently have a tenant. that It is responsihility to notify the occupant of the
mgaiNments-wn' el prior cc of a Certificate of cvpan 7.Signature
of Applicant Date
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All roof coverings to be Class "B" or better
Q nc autho�trtdagcm / Date