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CITY OF CUPERTINO
BUILDING DIVISION PERAUT
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BUILDING ADDRESS:
PERMIT NO.
18861 BARNHART AVE
TBD — TO BE DETERMINED
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OWNER'S NAME:
PERMIT ISSUE DATE
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CONTROL NO.
ARC HTTECi/ENGiNE17t:
BURRING PERMTr INFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I w licensed under provisions of Chapter 9 (commencing
withSecfull tionfsios3ofthe Businrstand Professions Code, and mylicense u
ADD 374SQ LIVNG—MASTERSUITE, 115SQ GARAGE, (NO
License ClassLk. N
Date Contractor
CONST
1 understand my plans shall be used uspublliic record
ON GARAGE UNTIL DESIGN REVIEW FOR EXCEPTION IS
APPROVED. REROOF 15 SQS . SANITARY IS SUNNYVALE'S
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am prompt from the Contractor's 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 requires the applicant for such permit to file a signed statement
Ft. Floor Area
.
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq.
(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
$60000
APN Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (3500).
37516056.01
❑ 1. as owner of the property, or my employees with wages as their sole compensation,
ns Required Inspections
will do the work. and the structure is not intended oroffered for sale (Sec.7044,Business
and Professions Code: The Contractor's License Law does not apply to an owner of
9 P
property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements arc 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.].
Erl, as owner of the property, am exclusively contracting with licensed contractors to.
convect the project (Sec 7044. Business and Professions Code:) The Contractor's Li-
cense Law does 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 the Comranor's
License law.
❑ 1 am exempt civ See , B & P C for this reason
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Owner Date
WO COM SATTONDECLARAT70N
1 hereby alrtnm under penalty of perjury one of the following declarations:
❑ 1 hive and will maintain a Certiliate of Consent to self -insure for Worker's Compen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is Issued.
❑ 1 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
(Ibis section need not be completed if the permit is for one hundred dollars (3100)
orlcct)
1 Certify that in the performance of the work for which thi amt is issued. 1 shall not
employ any person in any manner so As to become subjec a orkers' Compensation
Laws of California. Dat
Applicant
of Exemption, you should
become subject to the Worker's Compensation JftViSiDn3 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 then: is a convection lending a;ccy for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C)
Lender's Name
,
Lender's Address
I certify that 1 have rad this application and state that the above infonnatun is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize 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 grantingof this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date r
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 Safety
Code. Section 25532(a)7All
roofs shall be inspected prior to any roofing material being installed.
❑ Yes 94.,
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 Au Quality Management
all new materials for inspection.
Dlstricr7
C1 Yes W'0
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Halo & Safety Code. Sections 25505.25533 and 25534.1 understand that if the building
does not curve y have a tenant. tut dt�' responsibility to notify ft occupant of the
Date