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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
MMIK,
BUILDING ADDRESS:
PERMIT NO.
19620 STEVENS CREEK RTATD
SAN JO
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
A CONTROL NO.
(408)986-8711
ARCHITEC.' (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONrRACrOR's DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of DfvWon 3 of the Business and Priftasions Code, and my license is
in full force and effect.
REV FIRE POT COL DETALS, GRNDED STRS&EXHST FAN
License Class Lic.
Date Con
ELEC
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
DETALS, DLT &RLOCT SNTARY SWR LINS&GREASE WST
LINE &
Licensed Professional
OWNER-BUILDERDECON
I hereby affirm that I am exempt from ttneContractor's License Law for lire
RVS LNDSCP IRRGTN&PLNTG PLNS— ORIG#07060128
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
West he Is licensed pursuant to the provisions of the Contractor's 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 therefrom and the basis for the alleged exemption. Any violation of
5 0 0 0 0
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
not more than five hundred dollars (5300).
36906010 0 0
C] 1, 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 7044, Business
and Professions Code: The Contracwh License Law does not apply to an owner of
property who builds or improves themon, and who does such wort himself or through his
own employees, provided that such Improvemenns 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.).
t6l. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code.-) The Coetrar or't Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such pmjects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
.
❑ lam axe under . B & P C for this reason
Owner Dam t7f Z34
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workeez Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work 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:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed I the permit Ice fa one hundred dollars (3100)
or less.)
I certify that in the performance of the work for which this permit is issued 1 shall not
employ any person in any manncrW 1q.be�mc syb�'em to the Workete Compensation
'O/ MOM
Laws of Califomia. Dt > ohm
AppGant�'n
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subjcct.to the Workers Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shallbe 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 (See. 3097, Civ. C.)
Lender's Name
,
Lender's Address
I certify that 1 have read 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 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, cons 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 g$GUTA7iONS. f
2'?
Re -roofs /
Type of Roof
signatum�f/of/App�Tt�fl"/ucemtractor 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. Section25532(a)?
Yes �6No
All roofs shall be inspected prior to any roofing material being installed.
C:]
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or dcvicn which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes 16No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not car sly have a m nnL that It is my responsibility tonotify the occupant of the
rcgalremem hich m t be met priorto issuance of a Ccnificato r lY-
(o
Signature of Applicant Date
23(a Y
All roof coverings to be Class In"' or better
Owner orauthor6 d agent Date