07080104CY OF CUPERTINO
BUILDING DIVISION PERNUT
BUILDING ADDRESS: PERMIT NO.
10441 PHAR LAP DR JUMANGIT CONSTRUCTION 07080104
OWNER'
482 W HAMILTON AVE STE 236 09/07/2007
PHONE: SANITARY NO. CONTROL NO.
(650) 780-9704
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ARCHTTEC IENGINEER:
LICENSED CONTRACTOR'S DECLARATIUN
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
.with Section 7000) of Division 3 of the Business and rofessions Code, and my license is
n full force and effect -
Licensc Class Lic. M
Dale Contractor
XRCHVMCrS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I 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
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 Contraclur's License Law (Chapter 9
(commencing with Section 70(10) 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 arry applicant for a permit subjects the applicant to 5 civil penalty of
not more than five hundred dollars ($500).
❑ 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 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 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 Contractor's
License Law.
❑ 1 am exempt under See , B & P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-iasurc for Workers Compcn-
sation, 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
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:
57Z�f
Carrier. Policy No.: _Z—
67
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, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
N0710E TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to 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
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
Lenders Address
I certify that I have read this application and state that the above information is
cortecL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise 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,judgmcnts, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS. r�
Signature of Applicani/Contractor !/ Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceupantstore orhandle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
Cl Yes �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?
C]Yes ON.
1 have mad the hazardou atcrials re uiremcnts undcrChapter 6.95 of the Califor-
nia Health &Safety Code, Scc ' 25 5 3 an 25534.1 understand thaz if the building
docs not currently have a
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BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
196 SQFT ADDITION - MASTER BATH EXTENSION, BATH &
STORAGE AT BSEMENT MASTER BEDRM, BALCONY. 24 SQ
FT REMODEL - KITCHEN, WINDOWS, WALLS
Sq. Ft. Floor Area
32635042.
Issued by:
Re -roofs
Type of Roof
$145000
Required Inspections
Valuation
Occupancy 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 materials for inspection.
Signature of Applicant
A
Date