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CITY OF CUPERTINO�
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BUILDING DIVISION PEP VHT
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BUILDING ADDRESS:
PERMIT NO.
7513 LEEDS AVETBD
— TO BE DETE=NED
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OWNER'S NAME:
PERMIT ISSUE DATE
PHO
SkMtAlkl CONTROL NO.
ARCHITECT/ENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm this 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in mil force and effwL
ADD 798 SF (2 BTH , 2 BDRM , ENTRY) &RMDL
enxaass .� DaCo
Dale Contractor
MSTRBDRM, KITCHN,
ARCHrIECI'S DECLARATION
1 understand my plans shall be used as public records
DINERM , MBTH&FAMLRM&GARAGE
Ucmxd Professional
OWNER -BUILDER DECLARATION
1 hereby afrlrm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, hnprove, demolish, or repair any stmetum
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 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
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
13 0 0 0
APN Number
Occupancy Type
Section 70315 by any appUcant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($300)
36616019
❑ L as owner of the property. a my emplbyeU with wages as their sale compensation
.00
Required Inspections
will do the work. and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code. The Contractors Lime Law does net 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.).
4 L as owner of the property, am exclusively contracting with licensed contractors to
construct die project (Sec. 7044. Business and Professions Code:) The Contractors U-
cc= Law does not apply to an owner of property who builds or improves thereon. and
who contracts for such projects with a contractors) licensed pursuant to the Conuttetars
License Law.
❑ 1 am exempt under Sec. B & P C for this reaaom
_
OI/� Date
hereby affirm under penalty of perjury one of the following declarations
❑ 1 haw and will maintain a Certificate of Consent to self -Insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the perform&= of the
work for which this permit is issued_
❑ 1 have and will maintain Workers 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need tot be completed if the permit Is for oac hundred dollars (S100)
or less.)
1 certify that in the performance of the work for which this permit is issued. I shall rim
employ any person in any manner so as t ecomc sat t to the Wor ' Compensation
Laws of Califo!: Dater
Applicant /
Affl.[ . If, aflcr making this Certi realer 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 darned revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constnscdon lending agency for the performance of
rho work for which this permit is issued (Sec 3097, Civ. C.)
Lenders Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
cored I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby zuthoria 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, coos and expenses which may in any way accrue against said City
in consequence of the granting of this pernlL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCFREGULATION, ,, r /
v(��(be,
Re -roofs
Type of Roof
Si attireof App t/ onuactor Dater
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handlera hsdous material
-
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25332(a)? ❑ Yes a[3 N,,, /// o
All roofs shall be inspected prior to any roofing material being installed.
,future
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or 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 NfNo
1 have read the haardous materials requirements under chapter6.95 of the Califor-
nia Health & Safety Code, Section 25505.25533 and 25534. I understand that If the building
does not currently have a ==L, that it is nin 'lily tonodfy the occupant of the
U. sWhich m t