08100087 CITY OF CUPERTINO .�r� �M N
BUiLDiNC DIVISIONPERMIT '
BUILDING ADDRESS: PERMrr NO.
10679 MINETTE PL TBD — TO BE
OWNER'S NAME: PFRMrr ISSUE DATE
S CONIROL NO.
ARCHITECrfENGINEM BUILDING PERMrriNFO
BLDG ELECT PLUMB MECH
NEW 2—STRY SFDWL— O C7 O
3 0 o LICENSED CONTRACTOR'S DECLARATION FLR1 (15 3 3 SQ) FLR2 (7 5 3b' ]bescri tion
cmi 1 hereby affirm that I am licensed under provLsions of Chapter 9(commencing p
with Section 7000)of Division 3 of the Business and Pro6xsions Code,and my license is
H in full fora and effect.
z License Chao Lie.R
7 Date Contractor
ARCHTiELTS DECLARATION
I understand my plans shall be used as public records
7qU
Licensed PNrestional
y OWNER-BUILDER DECLARATION
N
I hereby affirm that 1 am exempt from the Contractor's License Law for the
in o following reason-(Section 7031.5,Business and Professions Code.Any city or county
which requires it permit to construct.alter.improve,demolish,or repair any structure
Z>y prior to its issuance.also requires the applicant for such permit to file a signed statement
o that he is licensed pursuant to the provisions of the Contmctoes License Law(Chapter 9 Sq.Ft. Floor Area Valuation
$ (commencing with Section 7000)o(Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exernpdom Any violation of
Section 7031.5 by any applicant far a permit subjects the applicant to a civil penalty or APN Number Occupancy Type
not mote than five hundred dollars(SSO(I).
❑L as owner of the pmpet)%or my employees with wages as their sole compensation.
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code The Contractors License Law toes not apply to an owner of Required Inspections
property who builds or Improve thereon,and who floes such wort himself or through his
ovvo emphoycu,provided that such improvements am riot intended or offered for sale.Ir.
however,the building or Improvement is sold within one year of completion,the owac-
builder will have the burden of proving that he did not build or improve for purpose of
Zak.).
L as owner of the property.am exclusively contracting with licensed contractors to
constrict 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 paujecu with a contractor(s)licensed pursuant to the Contractors
License Law.
❑1 am exemp n err Sea ,B&P C for this
Ow,its Date B
KERS MPENSAT70N DECLARATION
1 heroby tm under penalty of perjury ore of the following dcdarsthans
❑1 hove and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,of provided for by Section 3700 of the Labor Code,for the performance of the
wort for which this permit is isstied.
❑ 1 have and will maintain Wmimes Compensation Irsuru=,as required by Section
3700 of the Labor Code,for the petformanrz of the work for which this permit is istrted.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(hhls section rhet:d trot be completed if the permit is for ant hundred dollars($100)
or less)
1 cuvfy that in the performance of the wort for which this permit is issued.1 shall not
employ
Compensation provisions of the Labor Coda you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(--h 4 1 hereby affirm that there is Construction lending agency for the performance of
fl it the work for which this permit is Issued(Sec 3097,Civ.C.)
W IIm Lender's Name
z Lenders Address
U Q 1 testify that 1 have read this application and state that the above information is
IL coned 1 agree to comply with all city and county ordinances and state laws relating to
8 building construction,and heeby authorize mprescatalives o(this city to caterupon the
W above-mentioned property for inspacuon purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
Cn liabilldes,judgments,cosy and expenses which may in any way accrue against said City
consequence of the granuing of this
t.
U 4
in APPLI
CANT U ERSTANDS AND WIILL COMPLY WIIIi ALL NON-POINT Date h— ✓��
SOURCE
Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hita.oats materiai
as defined by the Cupertino Municipal Code.Chapter 9.12,and tlhc Health and Safety
Coda,Section 25532(4)?❑Yes .�No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes -ONO
1 have read the harardau materials requircmenu"ter 6.95 of dic Cali for-
nia Health&Safety Code,Sccdo s 25505.25333 and 25534.I understand that if the building
Dot