06080189BUILDING DIVISION PERMIT
BUILDING ADDRESS:
i Lem 1 (9 10
ARCHITECT/ENGINEER:
c ZLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
= a in full force and effect -
3 Z License Class Lic. #
Date Contractor
_ul
JARCHTTECI S DECLARATION
I understand my plans shall he used as public records
LU
F' Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
:10 following reason. (Section 7031.5, Business and Professions Code: Any city or county
u which requires a permit to construct, alter, improve, demolish, or repair any structure
y prior in its issuance, also requires the applicant for such permit to file a signed statement
t that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
- $ (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 more than five hundred dollars ($500).
0 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.).
DrI, 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 Contractor's
License Law.
0 1 am exemplaunder ,aec. B & P C for this reason
I hereby affirm under ett ty of perjury one of the following declarations:
-1 1 have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
ation, as provided for by Section 3700 of the Labor 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
5700 of the labor Code, for the performance of the work for which this permit is issued.
Ny Worker's Compensation insurance carrier and Policy number am:
-arrier 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 work for which this permit is issued, I shall not
employ any person in any az W c c subject to Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after ing this C Exemption, you should
become subject to the Worker's Compcnsatio visions of the Labor Code, you must
forthwith comply with such provisions ort ppermit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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 I 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
building construction, and hereby authorize representatives of this city to enter upon the
above-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 way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND Wl L COMPLY WITH ALL NON -POINT
SOURCE RF4PULATIONSt� , ,� � � YT/ . , i tet, t. • r
Signature of
Date
HAZA>tpPG'S MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Cock, Section 25532(a)?
0Yes 7 N
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?
0 Yes IWNo
I have read 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
r u,immentf—hich nftt bwnet WE to issuarcf a Certificate of Occupancy.
Owner or
Job Description
2 STORY SFDWL- 1ST 2618' 2ND 1311' GARAGE 615'
GARAGE 615' X 56.38 = 34,673.70 CUPERTINO
HOMES LLC REPLACES MINA HA AS OWNER -GRANT DEED
3q. Ft. Floor Area
32609015.00
Required In ections
W
l
Issued b)
Re -roofs
Type of Roof
Type
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 r iaterials for inspection.
Signature: of Applicant
All roof coverings to be Class "B" or better
Date