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BUILDING DIVISION PERNM
BUILDING AMPSM:
21870 GRANADA AVE
OWNER'S NAME:
PHONE:
xr DI6 QljaIWTIFE
ARCHITECr/ENCTNEER:
UCENSED CONLRACIUR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700U) of Division 3 of the Business and Professions Code, and my license is
in full forte and effccL
License Date ClanContractor r'i i I f1
ARCHr ECI'S DECLARATION
I understated my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I busby shuns that I am exempt from the Contractors license Law for the
following mason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to conss=4 alter. Improve, demolish, or repair arty stroctam
prior to is Wuw= also requires 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
(commenting 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
Section 7031.5 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 sob compensation,
will do the work, and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Contractors L.keox Law does mot apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
ma employees, provided that such Improvements are not intended or offered for sale.1L
however. the building or improvement is mad within one yew of completion, the owner -
builder win have the budges of proving that he did not build or Improve for purpose of
sale.).
owner of the property. am exclusively contracting with licensed cmtractars to
TDOMW the project (Sec 7044, Business and Professions Cede) The Contractors IJ-
cerae saw does out apply to an owner of property who builds or Improves thereon. and
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License saw.
❑ I am exempt and Sec B & P C f 9r this
Owner Date OK
RKER'S COMPENS ON DECLARA
ulTION
1 bacby affirm mulct one of the following declarations:
❑ I live and will maintain a CetiBate of Consent to self -Insure for Workers 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 Worbr!z 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 Compensadcm Insurance curia and Policy number are:
Carrier-. Polley Nor
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE.
(Thissection need not be completed if the pamft is fa one hundred dollars (S100)
or leas)
1 certify that In the performance of the work fa which this permit is Want, 1 shall not
amplay any person I any manner so t b co bject to the Worlmts' Compesation
Laws of Califomi a
Applicant
NOTICE TO CANT: I , after this Certificate of Excmpdon, you sbouW
become subject. to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONymu TION LENDING AGENCY
I hereby affirm that there is a. construction lending agency for the performana of
Cite work for which this permit Is issued (Sec. 3097, Civ. C)
Lenders Name
Lenders Address
I certify that I have read this application and sure that the above Information is
correcL 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hemb)r authorize represen atfves 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 expeoaea which may In any way acme agalost said City
in consequence of the granting of this permit.
APIPLICAPITUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
soUR
sipplicafiaeonDate
U ATERIAIS DISCLOSURE
Will the applicant or future building occupant. stare or handle hazardous material
as defined by the Cupertino Municipal Codc. Chapter 9.12. and the Haiti and Safety
Code, Section 25532(t)?
❑Yes ❑No
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
District?
❑Yes ❑No
I have mad the hanndws materials rcquimmcnu undo C�apler 6.95 of the Califor-
nia Health & Safety Code, Scanons 25505. 25533 and 25534.1 understand that if the building
s not c ndy have a tenant- that It is my responsibility to notify the occupant of the
does
lvhic must ha met or to issuance of a Certificate o
(( / o a '
MAMI I Nu.
PI RMrr ISSUE DATE
A CONTROL NO.
BUILDING PERMrrINFO
BLDG ELECT PLUMB
Job Description
ADD (395SQ)@REAR HSE INCLD 1
BTHRM,IBDRM,IFAMRM&RMDL KTCH(170SQ)
Ft. Floor Area
APN Number
35716024.01
Required Inspections
Issued by:
Valuation
Occupancy Type
Date
Re -roofs
Type of Roof
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
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class's" or better
Date