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CITY OF CUPERTINO
BUILDING DIVISION PERMIT�TRAT
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BUILDING ADDRESS:
PERMIT NO.
18760 TILSON AVE
TBD - TO BE DETERMINED
OWNER'S NAME:
PERMIT ISSUE DATE
:
A O. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am Been under provisions of Chapter 9 (commencing
with Section 7011U) of Division 3 of the Business and Professions Code, and my license is
in full force and effect_
2 STORY HOUSE -LIVING 1, 845' , BASEMENT 1., 027' ,
Date Contractor
Date contractor
cont#
GARAGE 418 ' -ATTACHED 2ND UNIT 552 ' -2 GAS& 2
ARCHTrECTS DECLARATION
1 understand my plans shall be used as public records
ELECTRIC METERS.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, 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 requires the applicant for such permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed. pursuant to the previsions of the Contractor's License Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
4 6 5 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
37517040 .00
1, as owner of Lhaproperty, 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. 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 dots 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.).
ZI 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
ccnse Law dots 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 time Contractor's
License Law.
❑ lam exempt(unndder Sec , B & P C for this reason
Owner�
DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum for Worker's 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 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 Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
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I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner s beco c s jccl to the Workers' Compensation
Laws of Cnl(fo is Dat
Applicant
NOTICE TO . after making this Certificate of Exemption, you should
become subjectTo 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
1 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.)
Lenders Name
Lender's Address
1 certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinance and state laws relating to
building construction, and hereby authorise 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 permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date/ ,
SOURCE
Date
HAZARDOUS MATERIALS DISCLOSURE
Will 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 Safely
Code, Section 25532(a)?
❑ Yes �l'SNo
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 use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
YesMu
I have read the hazardous materials requiremc= under Chapter 6.95 of the Cali for.
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand Nat if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requirements to issuance of a Certificate of Occupancy.
Signature of Applicant Date
' " 1_1 , � °4�7t 4-A
All roof coverings to be Class'}'' or better
Owner or autho '.rat a Date