08080033 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACT,ORIN,F�ORMATI,gN
BUILDINGADDRESS: PERMIT NO.
10215 EMPIRE AVE LOT 2 TBD TO BE ETERMTNED ngognnvi
-
OW PERM37 MUE DATE
'2888
p SA CONTROLNO.
ARCHIIECT/ENGINEFA:
BUILDING PERMIT INFO
NEW 2 STORY SFDWL-LIVING BLDG ELECT PLUMB MECH
�Op LICENSED CONTRACTOR'S DECLARATION 2, 558 ' W/ATTACHED GAI �l�escriUon
iIu 1 berebY affirm that 1 am Reeved under provisions of Chapter 9(commencing • , P -
U. whh Somion 70150 of Division 3 of the Business and Proicesimot Cede,and my licenseis
^?y in full forte and effect ,
j z License Claw Lm.P
s„G Date Canuacmr
ARCHITECTS DECLARATION
U I undersand my plans mall he used u s
public record
DI
!U
Lrtcnsed Professional
3OWNER-BUILDER DECLARATION
I hemby affirm Nal I am exempt from the Conaaaors License Law for the
00 following muen.(Salon 70314,Business and professions Code:Any city or county
e m which requires•permit m cnnnnc4 alma improve,demolish,or repair my structure
prior m its Issuance,also requires ilc applicant forsuch permiuo file a signed sim mem
s< thathculicevcdpurmantmlhe,provisionsoftheContractor'sUes.law(Chapter9 Sq.Ft. Floor Area Valuation
xl-0 (commencing with Section 700))of Division 3 of the Business and Prefmorts Code)or
y $
that he is eaompt tMaefram and tic basis for the alleged exernplom Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of APN Number Occupancy Type
net more than live Wanted dollms(5500).
L u owns of the property,m my employees with warn u then sole mmpew0an,
w d Professions
Coat-The
Communotmmmense L fw does;
to An Bum of Required Inspections
and Property
wh obu Code The Conmcmrs License!and dao rot apply m an owner is 9 p
manonY who buildsviintproteathenen,and who men suchwork throll fed Nevar-hu
ow meront theWilding
idistsuchimpmwmmtsartne Your' fe auldem.mred formic.If.
however,the dulling or improvement 4 sold within oro Year W completion,the owmr-
buimer win have du burden of PrOHng Nat he litl rot ddW a Improve far papose of
sae.}
I.As owner of me Property.am eadmi sly conussting with line boa mnuanars a
rout the Project(See 7014,Emboss and Professions,Code:)Too Contractor's Li-
taw saes vat appy m an owmr of property who builds or improvm Merton.AM,
who corona fm such projects with s eonuanmr(s)licensed puranant to the Comrsmars
Lam.taw.
❑lam'
1 hereby aln=under p ly of perjury one of the following declarations:
❑Ihsve and will maintain aCeNOauof Cmn,nuv self-insumforWmkerCCaopen-
ration,As provided for by Section 37M of the labor Code,for the performance of the
wart for which this permit is issued.
❑I have and will maintain Warkeh Compensation Insmance,As mquired by Suction
37M of the Labor Code,(W the performance of the work for which this permit is issued. '
My Work es Compensation insurance artier and policy number am: '
Cartier. Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(7Tl,sccdm need on,be completed ifft permit is foram,hundred dollars($100)
or leu)
1 certify that in
thisCertificateof of Exemption,You
d:<ame subject m the Wohero Compel shin pmvisihal of the talc Codi you most
�Z forthwith comply with such provisions or this permit shall be duemM rtwkrA
ZO CONSTRUCTION LENDING AGENCY
[-i I hereby alarm that than,u a communion ending agency for do performance of
E
the,work for which this permit is issued(Sm.3097.Civ,C.)
W�0 Lenders Name ,
z Lumices Add=
U Q 1 coolly dost I haw read this application W sum this Om above information is
LL ^ coat.I agree m comply with all city and county oNinuuzs and able laws rtlail m
p SV^ building construction,and hereby mmodmrep=natives ofthu city to emerupon the
W above-ruenfioned property for inspection purposes
(Wd agree to save.indemnify and keep harmless the City of Cupertino agaimt
jj liabilitia,judgments,costs and expenses which may in my way mcme against said City
of due grauting of this
C)z APPLLIA MCUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
nogrDam
H OUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futon building oceuPant amte or handle ha urns material
u defined by do Cupertino Muplcipal Codc.Chapter 9.s,,and do Health and Safely
Cade,Suction 25532(1)? / All roofs shall be inspected prior to any roofing material being installed.
❑Ya Na
Will the applicant or fu rt battling occupant sac eyvipmmt err devises w-ich If a roof is installed without first obtaining an inspection,I agree to remove
omit hae los Or emu ero nti ss defined by the Bay Ana Air Quality Management all new materials for inspection.
District?
❑Ya No
'9 (have mad the hound material,mgdieemmus mder,�.pmr6.95 ofhe Califor- .
nu Halth&Safety Cade.Savom 25505.25533 and 75334.T oMersuend Ihetifthe Wilding .
dans Oct currently haw a Imam,med it is my mspomibility to notify the oceupent of the
aqui
Dam