08070008CITY OF CUPERTINO'*ua':f
`� P "� "hR"'
BUILDING DIVISION PE16UT
BUILDING ADDRESS:
PERMIT NO.
22580 SAN JUAN RD
TBD — TO BE DETERMINED
08070008
'
SANITARY NO. CONTROL NO.
ARCHITER/ENGINEM'
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
o
Job Description
y afOthat 1 am licensed under previsions of (commencing
1 barebm
with Section 7001)ofDivision 3 oftha Business and Professions code, and my ]team is
REV ADD NEW HOLDOWN H1@NEAR W. WLL & AT CORNR OF
in full tom and effut
IxanseClane Lk.11
BASMNT; TO ADD WL PNL ARND ACCESS WNDW IN
Dam Contractor
ARCHITECT'S DFCLARA71ON
BASEMNT;
I undersued my plana Mali be used u public records
ORI G #06050101
Licensed Pmmuioml
OWNER -BUILDER DECLARATION
-
1 hereby aflinn that 1 am m unpt from the ConvanWa License Law fur No
following mamn. (Section 7181.5, Business and Prefeuiom Cmlc: My city of coumy
which requires a permit As conmucL alter, improve, demolish. or repair any M"ct"re
prior bits issuance, also require Ibe applicant for such Permit to file a signed SMUNAMt
that he is licensed to um Conuacutt'a License Law (Chapter 9
Sq. Ft. Floor Area0
Valuation
purmant provisions of the
(commencing with Suction 7000) of Division 3 of the Business send Profusions Code) or
that he is oumpt dtateftom and the bub for the alleged momption. Any violation of
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant or a civil penalty ofNumber
cwt more dun five hundred dinars ($5001.
3 4 2 18 0 4 4 .' V V'
❑1,uownerof Nepmperty.wmyemplayeuwithmg uNehmkeompensedon,
Required Inspections
ness
Anel meee`nO.fpplyy m: 'mandr
PPrro�fud�caddaa' TLn�Cont�lor'snkuesima�� Of
property who builds or improves t ercon. and who does such work himself or through his
awn employees, provided that such improvements scent intended urolfered forsele lf.
however, the building orimprevement Is sold within ore yen ofearepktion. Ne owner -
builder will have the burden of proving that Im did ret Want a improve per purpose of
ukd.
1, an owner of the pmpetty. am esclelvely coemuting with Seemed commuters in
tact Ne preject (Sec. 7044. Bawa and professions Cade:) The Commuter, U.
cause Law, does not apply m an seater of property wino build, or Improve rhemeen, and,
who contract, for such prefects with a comeanor(s) Hermon! parsmns to the Conmewra
License law.
❑ I om eSee .B k P C far Nb moon
L/xelmpt under
i
'
�/1 WOR BRS COMPEIi ATiO ECLARATION
I hereby effirea under Mosby of perjury ane of the fallowing declaada e:
❑1have and will maiouin• Cemfrem orcoment to self-imum for war .compeo-
sation, As provided for by Section 3700 of the Leber Cade. for the pertarmmee of the
work for which Nb pemtt is issued.
❑ 1 have and will maintain Workers Component Insurnm, As required by Section
37W of the LAW Cade. for de performame of the work forwhich thin permit in issued.
My Workers Compensation Insurance carrier and Policy number are:
-
Carsier•, Pellcy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Tbb sttaan aced was be cempkmd if the pctmft b (marc hundmadollan (5100)
or Anne)
I codify that in the performance of the w rak fur Nis permit b Issued, I ,hall not
ewhich
employ any Mananme
Mann to y onc'm WuL wbj=L he the Wmken'Compenudom
Laws a(C is to Mor
Appl' 1
NO'1ICE APP CAM: If.'afm eking L CentBum of Eumpttan, you Mould
haeme subject the Worked Coit pawdon mvisionsof tec Lshor Cade you mum
forNwith comply with such provision or Nb Permit still be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alEnndot dorm is. construction lending all for the pert rmuwe of
the work for which this Permit b wood (Sec. 3097, Civ, C.)
Lenders Nurse
,
Landers Addma,
1 comfy that 1 have read this application and ,tate thal the above irdormatiun b
comet 1 eget to comply with N city and county ordinances and some laws relMng m
- --
building comon ction, sea hereby sumorien representatives of Nis city to enter upon the
above-mendoned property, for inspection purpose.
(We) as= to save, indemnify and kap hamlw the City of Cupertino against
lin iabilities, judgmof the cnm. cmu and Of expenses which may In any way tame egdnst sod City
geUNDERSTANDS
C�
7
APPLICANT AIND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 't"
50 RCEREGU ATONS.
Re -roofs
Type of Roof'��-
-7
_ _
rgnuu afAppit H RDOUSMATERIALSDISCLOSURE Dam
Will the applicant or future W ilding acupsnumm w handle haumous Outco d
As de0ad by the Cupertino Municipal Code, Chaim, 9,13, ared he Health and Safety
Section 25532(4)?
Oyu [�Na
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 futum building occupant use equipmeal or devices which
emit husmous dr cauccona s As dcfiad by de Bay Arca Air Quality Management
all new materials for inspection.
District?
uqo
❑Yes
I have mad the hnsmaus materials requirements unchoormkr 6.95 ofthe Caller.
aller-
ma Health &
naHeallhk Safety Code. Sections 25S05.25533 and 25534.1 undcmwd that if to balding
does ret currently haw • users, than, it 4 my mponsibility On notify the occupant of tic
req" ments which mint met priarm� ofaceeilA
namafoccupanry.
Signature of Applicant Date
All roof coverings to be Class'V' or better
Gwner
verinfluxt agent Dom
CITY OF CUPERTINU
BUILDING DIVISION PERNIITC� ITR ETOR INFQR TIfO1 .. _•.
BUILDING ADDRESS: PERMIT NO.
22580 SAN JUAN RD TBD - TO BE DETERMINED' 08070008
OWNER'S NAME: PERMIT ISSUE DATE
07/17/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
O 0 LICENSED CONTRACTOR'S DECLARATION
iu p I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z uUr with Section 7000) of Division 3 of the Business and Professions Code, and my license is
R, in full force and ecL
i ? ffeLicense Class Lic, #
Date Contractor
ARCHITECTS DECLARATION
7 ¢ I understand my plans shall be used as public records
)yU
UO y Licensed Professional
y OWNER -BUILDER DECLARATION
jag 1 hereby affirm that 1 am exempt from the Contractors License Law for the
.00 following reason. (Section 703 1.5, 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 file a signed statement
= G Thal he is licensed pursuant to the provisions of the Contractor's Liccnsc Law (Chapter 9
2 t— (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mon: than five hundred dollars (5500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work. and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's 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.).
io/I. as owner of the property, am exclusively contracting with licensed contractors to
istmct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law docs 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.
❑ I am exempt under See. B & P C for this mason
Owner r !xi � id
V ynORKER'S COMP NATIO ECLARATION
1 hereby aflum under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's 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 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 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 drat in the performance of the w rk for which this permit is issued. I shall not
employ any person in any mane 'so as
Laws oLfcbncobpe subject to the Workers' Compensation
ia. arc U
Applic
NOTICE T4 APPLICANT: If, after making �hj& Certificate of Exemption, you should
become subject to the Worker's CoW pcnsation`provisions of the Labor Code, you must
.J ,Z forthwith comply with such provisions or this permit shall be deemed revoked.
7— O CONSTRUCTION LENDING AGENCY
,..n
F.n rr I hereby affirm that there is a construction lending agency for the performance of
�,. the work fur which this permit is issued (Sec. 3097, Civ. C.)
WPI, Q Lender's Name
a Z Lender's Address
L) p I certify that I have read this application and state that the above information is
Uy — coned I agree to comply with all city and county ordinances and state laws relating to
0 V building construction, and hereby authorize representatives of this city to enter upon the
4Wi above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
to liabilities, judgments, costs and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO RCE REGULATIONS. /
i QJi 1"A h(1 anA , d I_ -7 f 7 Ill
Signatufe of Applicant/C")atractor — I Date
H M
DOL1 ATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 912, and the Health and Safety
Code, Section 25532(a)7
❑ Yes CV/No
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
District?
❑ Yes Uio
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
mquiRments which mum,kc met prior to isst�ancc of a Certificate of Occupancy.
or a'uthorixed agent 1_1 V Date
BUILDING PERMIT INFO
BO ELECT PLUMB MEOCH
Job Description
REV ADD NEW HOLDOWN H1@NEAR W. WLL & AT CORNR OF
BASMNT; TO ADD WL PNL ARND ACCESS WNDW IN
BASEMNT;
ORIG #06050101
Sq. Ft. Floor Area I so Valuation
3 4 218 0 4 4 .IVV Number
Required Inspections
Re -roofs
Type of Roof
Occupancy Type
7-(-7 ,�,C-
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
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be CIass rt."' or better