07090030CITY OFCUPER'1'11vu �7����+��I�tTTON�
BUILDING DIVISION PE1�MI
PERMIT NO.
Bu1L1fx�rDRSTANFORD PL QSP CONSTRUCTION 07090030
ti PERMIT ISSUE DATE
GR'S NAME:
ERIC TOM 732 SCOTT BLVD 09/17/2007
I I SANITARY NO. CONTROL NO.
ARCHITEC'rfENGINEER:
laz0 LICENSED CONTRACTOR'S DECLARATION
Lu P I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
-0
y in full force and effe
, rnr Z License Class Li
o Date Contractor
:F m ARCHITECTSDECLARATIO
i a.t
< 1 understand my plans shall be used as public records
iyU
W Licensed Professional
y OWNER -BUILDER DECLARATION
} 1 hereby affirm that I am exempt from the Contractor's License Law for the
q C 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
a �+prior to its issuance, also requires the applicant for such permit to file a signed statement
? a 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 Cade) or
r that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subject% the applicant to a civil penalty of
not more than five hundred dollars (5500).
[:11. 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.).
❑ I, 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 Caw 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 Caw.
❑ 1 am exempt under Sec. B & P C for this reason
,er Date I
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
(408) 9�1-8752
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
REVISION - MOVE W/D FRM CNTR TO ENTRY,
(ORIG #07060034) BDRM 2 CLST MVD, BTHRM(CTR)ADD
SHWR, MSTR BTH DR & SNK MVD, KTCHN WL OPND, SCND
] 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
vork for which this permit is issued.
] I have and will maintain Worker's Compensation Insurance, as required by Section
1700 of the Labor Code, for the performance of the work for which this permit is issued.
Ay Workers Compensation Insurance carrier and Policy numberC
Carrier. S A -t f u' Policy No.: `�
CERTIFICATE OF EXEMPTION FROM W S'
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 manner so as to become subject to the workers' Compensation
Laws of California. Date
Applicant
NOTICE 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
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
Gender's 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 authorne 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 permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU�REGULATIONIS. Q O
Signor f Date
HAZARDOUSA ALS DISCLOSURE
Will u urc t mg occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
de, Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminant% as defined by the Bay Arca Air Quality Management
District?
❑ Yes ❑ No
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
does not currently have a tenant, that it is my responsibility to notify the occupant of the
mauimments which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized
35932023'
Issued by
Re -roofs
Type of Roof
Ft. Floor Area
$0
Required Inspections
Valuation
Occupancy "lype
All roofs shall be inspected prior to any roofing material being installed.
If a roof .s installed without first obtaining an inspection,.1 agree to remove
all new materials for inspection.
Signaturc of Applicant
All roof coverings to be Class "B" or better
Date