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CITY OF CUPERTINO
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BUILDING DIVISION PEPdMn
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BUILDING ADDRESS:
PERMIT NO.
21011 QRFENTXAF DR
WELKIN
OWNER'S NAME:
INC
PERMIT ISSUE DATE
6 6 8
CONTROL NO.
408)733-0188
ARCHITEC IENGDMML
BUILDING PERMIT INFO
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BLDO ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I botchy affirm that I am licensed under povisions of Chapter 9 (rnmmencing
with Section 700M of Division 3 of the Busiricas and Professions Code, and my license is
in full force and clad.
DEMO 1 STORY
Class Lk.
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PER GREG WILL EXTEND PLAN CHECK PROCESS UNTIL
ARCHITE 17S DECLARATION
I wxiersland my plans "I be used as public records
Lieonsed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's Ucense Law for the
following reason (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to congruct. alter, improve, demolish, or mpair any soucture
prior to its issuance. also requires the applicant for such permit to fie a signed statement
Sq. Ft. Floor Area -
Valuation
that he is licensed pursuant to the provisions of the Contractor's Lh ensc Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he Is exempt thetefto a and the basis for the alleged csemptiom Any violation of
APN Number
Occupancy Type
Section 7031.5 by goy applicant for a permit subjects the applicant to a civil penalty of
not more dun five hundred dollars (5500).
32608056 .00
❑ L as otter or the property, or my employees with wages as their sore compensation.
Required Inspections
will do the work, and the sanctum Is not intended or offered for sae (Sec.7044. Business
and Professions Coat The contractor, es net apply Lo an , I k= Law doowner of
property who bads or improm thereon, and who does such work himself or tiuoegh his
won employees, provided that such improvements are not intended or offered for sale. If,
however. the building or improventennt is sold within one yen of completion, the owner -
builder will have the burden of proving that be did not build or improve for purpose of
as owner of the property. am exclusively contracting with licensed contractors to
constrict the pojnxt (See 7(Y1. Business and Professions Code:) The Coatracur's Li-
ocuse Law does not apply to an owner of property who builds or improves thereon, and,
who conuaets for such projects with a contractor(s) licensed pursuant to the Contractors
Licence Law.
❑ I am exempt under Sea , B & P C for this reason
Owner ��tit ,
hereby affirm under penalty of perjury one of the following declarations:
❑ i ha.e and will maintain a Certificate of Consem Lo self -insure for workers 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code_ for the performer ere of the work for which this permit is Issued
My Worker's Compensation Insurance carrier and Polley number am:
Cartier. Policy No.
-5cEmFnoN
CE=cA7E FFROM wORKERS'
COMPENSATION INSURANCE
Cihis section creed not be completed if the permits for one hundred dollars ($100)
or Ins.)
I certify that In the performance of the work for which this permit is issu I shall not
employ any person in
become subject to the Workers Compensation provisions of the Labor Code, you mom
forthwith comply with attch provisions or this permit shall be deemed revoked.
)
' CONSTRUCTION LENDING AGENCY
1 hemby afrrrm that there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
L.eshdoes None
(.coders Address
j I certify that 1 have read this application and sure that the above lnfm=don is
c comecL I agree to comply with all city and county ordinances and state laws relating to
' building construction, and hemby authorize representatives of this city to enter upon the
above -mentioned property for Inspection purposes
(w0) agree to Aye. indemnify and keep harmless the City of Cupertino against
j IlLbilitica jodgmneou erns and expenssn Loses may In any way accrue against said City
in consequence of the granting of this permit.
j APPUCANT UNDERSTANDS
.
Re -roofs
Type of Roof
Sigma tare pplicamiACmnmctor Dale
CT. HAZARDOUS MATERIALS DTSOSURE
W W the applicant or future building occupant store or handle hazardous; material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Cone, Section 25532(a)7
Yes 0No
All roofs shall be inspected prior to any roofing material being installed.
Cl
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 hrrardous air contaminants lined by the Bay Area Air Quality Management
all new materials for inspection.
DiatdcO
Cl Yea No
I have read the hazwdass materials rcquircrmcnts under Chapter 05 of the Califor-
nia Heal" Safety Code, Section 25505. 25533 and 2 NL I wdcrsnnd that if the building
does not currently have a tertant, that it is my responsibility to notify the occupant of the
rcgnucm ich nmbemet issuaQccora te0rot�,Ky
ignature of Applicant Date
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All roof to be Class's'' or better
Owner wthorvedagrnt Date
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CITY OF CUPERTINO�
PERNM
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BUILDING DIVISION
BUILDING ADDRESS:
PERMrr NO.
21011 GREENLEAF DR
TBD — TO BE DE
OWNER'S NAME:
!
6&ItA O. CONTROL NO.
ARCHTTEcr/E NGHNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACIOWS DECLARATION
Job Description
1 hereby affirm that I an licensed under provisions of Chapter 9 (commencing
p
with Section 7000) of Division 3 of the Business and I mfessiorts Code, and my lice se is
in full force and effect.
RMV (E) HSE & BLD NEW 2 STORY SFDWL
D Classcntrram*
PER GREG PERMIT WILL BE EXTENDED TILL 12/18/2008
ARCHr1ECPS DECLARATION
1 understand my plans shall be used as publicrecm
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7030, Business and Professions Code: Any city or county
which requires a permit to construct, alter. hnprove, demolish, or repair any struzure
prior to its issuance, also nqudres the applicant for such permit to file a signed statement
That he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area •
Valuation
(commencing with Section 7000) of Division 3 of the Business tad Professions Code) or
that he is exempt therefrom and the buds for the alleged exemption. Any violation of
6 0 0 0 0 0
APN Number
Occur
Occupancy
anType
Section 7031.5 by any applicant for a permit subjects the Applicant to a civil penalty of
PAL mitre rocs five hundred dollars (s5oo>.
32608056.00
.
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
win CIO the wok am the structure is not intended or offered for sale (Sec. 70", Business
and Professions Code: The Contractores s License Law donot apply to an owner of
Q p
property who builds or improves thereon, and who does such wort himself orthroegh hat
own employees, provided that such improvement& are not Intended or offered for sale If,
however, the building or improvement is sold within one year of completion, the owner -
bud have the Wrdra of proving that he did not ddld or improve for purpose of
sa
L as owner of the property. am exclusively contracting with licensed contractors to
wnelro:t the project (Sec. 7044. Business and Professions Code:) The conuacmrs Li -
curse Law does not apply to an owner of property who builds or improves thereon. and .
who contracts for such projects with a cant actors) Licensed pursuant to the Contractors
Liceme Law.
❑ T am exem txunder See B k P C far
Owner C
v WORKER COMPENSATION DECLARATION
I of perjury one of the following declarations: .
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Canpen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is issued
❑ I have and will maintain Workers Compensation lasttrance, as required by Section
3700 of the Labor Code. for the performance of the wart for which this permit is Issued.
.
My Worker's Compenudoe Insurance carrier and Policy number we:
Carrier. &Policy No.:
C _RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhls section treed not be completed If the permit is for one hundred douara (f 10%
or less)
I certify that in the performance of the wait for which this —11 is [sued, 1 s not
employ any person in any manner so u b
Compensation provisions of the Labor Code, you must
-
forthwith comply with such provisions or this p"mit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performer¢ of
the work for which this permit is issued (Scc. 3097, C•rv. C.)
Leaders Name
tender's Address
I certify that I have read this application and stale that the above infurmadon is
correct. 1 agree to comply with all dLy and county ordinances and state laws relating to
building construction, and hereby wtharim representatives of this city to enter upon the
above -mentioned properly for Inspection purposes.
(We) agree to save, indemnify and keep harmless the Clty of Cupertino agaimt
0abilitim,)udgmemu, costs and expenses which may in any way aceruc against sad City
in of this
APPLLICANr UNDERSTAuence of
occupanL store orhandle hanudous mace W
as deftned by the Cupertino MurAd Code. Chapter 9.12. and the Health and safety
Code, secdo 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will dic appliant or future building occupant Use egaiprom or devices which
cmii hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Disulet7
❑Yes o
1 have read the hazardous materials n quimmems under Chaptmr6.95 of the Califor-
nia Health k Safety Code. Sections 25505, 25533 and 25534.1 untletsand that If the building
does not currently have a teranL, the It is my responsibility to notify the occupant of the
regadrerrrertuw)+i bloc •onto• r.certinaeeora
Signature
to be Class " " or better
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Data
Owner o<wlhorvtd agent Dates
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