08060182CITY OF CUPERTINO
BUILDING DIVISION PERNHT
�Y Q V
BUILDING ADDRESS:
PERMIT NO.
22445 CUPERTINO RD
SAMUEL CONSTRUCTION
OWNER'S NAME:
PERhff1' ISSUE DATE
,2668
PHO .
SA CONTROL NO.
ARCHr=/ENGINEER:
BUILDING PERMrr INFO
DEMO (E)TRASH ENCLOSURE &
BLDG ELECT PLUMB MECH
O o o a
LICENSED CONTRACTOR'S DECLARATION
CONSTRUCT NEW 144 0 ' Job Description
I hereby affirm that I 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 full force and effect. —�/f,.��
License Class Lk. •
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby aRrm that I am exempt from the Contractors License Law for the
following reason. (Section 70315, 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 regttires 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 and Professions Code) or
that he is exempt thetefmm and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
ane
P Y Type
Section 703 M by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec, 70", 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
salt.).
❑ I, as owner or the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Coutrsctor's Li-
cense Law does not apply to an owner or property who builds or improves thereon, and
who contract& for such projects with a contnctar(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under See. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of pnjmy one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for WorkefsCompen-
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 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 Worker's Compensation Inasurceaerd Poli
ay 2Z
Carrier. t302P�PJJPolicy No.:
CER71FICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nolbe completed it the permit is for one hundred dollars (S100)
or Icss.)
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 Worim' 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 arum dual them is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lenders Namc
,
Lenders Address
1 certify that 1 have mad this application and state that the above Information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize represtntad cs 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 &caw against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL. COMPLY WITH ALL NON -POINT
Issued by: Date�-
SOURCE REGULATION
o)>
Re -roofs
Type of Roof
Signature of Applicant/Contrac Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantor future building oceupantstorc or handle hazardous material
as defined by the Cupertino Municipal Code- Chapter 9.11 and the Health and Safety
Code, Section 25532(a)7
❑ Yes lip
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
Will the applicant or future building occupant test equipment or devices which
emit hazardous air contaminants as defned by the Bay Arcs Air Quality Managcmcnt
all new materials for inspection.
/i
District?
El Yes G.✓"'
1 have read the hazardous rn=riaLs requirements under Chapter G95 of the Califor-
nia Health & Safcly Cadc, Sections 25505, 25533 and 25534.1 understand dot if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
mquiremen5� hkh must met prior to issuance of a Certificate of Oc cy L
nvl�r�o
Signature of Applicant Date
C5�1
All roof coverings to be Class's" or better
Date '
Owner or authorized agent