06100012z
0
Z
C
4
:.7
. 0
)z
)C)
r.
U
. ICI
)z
CITY OF CUPERTINO
BUILDING DIVISION PERNUT
q. '
CON" :1�wb OIl�7
BUILDING ADDRESS:
PERMIT NO.
10430 S DEANZA BLVD
TBD - TO BE DETERMINED
06100012
OWNER'S NAME:
PERMIT ISSUE DATE
02 28 2007
PHONE:
SANITARY NO. CONTROL NO,
ARCHITECi/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby licensed Chapter 9
Job Description
affirm that I am under provisions of (commencing
With Section 70DO) of Division 3 of the Business and Professions Code, and my liccrm is
SITE WORK- CONCRETE STAIR WITH HANDRAIL & RAMP
in full force and effect.
License Class Lic. N
'
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt (rum the Contractor's Liccnse 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 ptrmii to file 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
$` 6 0 0 0
that he is eumpt 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
APN Number
Occupancy Type
not more than five hundred dollars (5500)_
36940015
❑ L as owner of the property, or my employees with wages as their sole compensation,
will dothcwork,andthemctureisnotintendedoroffercdforsaic(Sec.7044,Business
Required Inspections
and Professions Code The Contractor's License Law does Dot apply to an owner or
q p
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 conuacdng with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's U.
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
-
L.icense Law.
-
❑ I empt u der eF., " -- -, BA PC for this reason
Owne�
- eWORKER'S
-, —
�"'4
COMPENSATION DECLARATION � � �� _ _
� - — "
1 hereby affirm under penalty of perjury one of the -following tlec)arafions:-.- -
�✓ /�' .
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen.
cation, 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 regtrired 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 EXEMPf7ON FROM WORKERS'
COMPENSATION INSURANCE
Mis section need not be completed if the permit Is for one hundred dollars ($100)
or loss.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
cvploy, any person in any m cr spas subject to the Workers'Compensadon
Laws of California, Dare .—)
Applicant
NOTICE TO APPLICANT: If, after making this Ccruficatc of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed mvokcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm chat 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
'
Lenders Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim representatives of this city to enter upon the
-
above-mcntiuncd 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.
\
Re -roofs
Signat afApplicanUContraetor Date
HAZARDOUS MATERIALS DISCLOSURE
�%`--
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as refined by the Cupenino Municipal Cook, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑ Yes C] No
prior
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 hazardotu materials requirtmems under Chapter 6.95ofthc Califor-
nia Health do Safcty Cock, Sections 25505 533 and 25534-1 understand that if the building
does not currently h a tenann, i it my responsibility to notify the occupant of the
Ccrtificatc of Occu ry.
�+
Signature of Applicant Date
All roof coverings to be Class "B" or better
Own i7rd
r authorgent Dale
a