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CITY OF CUPERTINO
a t K1+""BUILDING
DIVISION PERMIT
4CONTRAG QRANF,ORMA�1I0NN''
BUILDING ADDRESS:
PERMITNO.
I
OWNER'S NAME:
PERMIT L95UE DACE
e 8 a
p
A CONTROL 10.
408)436-8151
ARCHITEC /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hmeby anion dust 1 am Ixensetl under pmvisloa of pw 9 (comm
tt
p
with Sccuon 7") ofDivison lot the Bnsn dProf de, my
b rtrn info at as Q
in funse 3
RMDL KTCHEN(120SQ)&BTHRM(28SQ); NO RE-RF & SOME
❑tien U Lk.
Dale "a I.,
STRUCTURE
ARCHfrECI-SDECLARATION
1 understand my plans shall W need ss Public records
Licensed Professional
OWNER -BUILDER DECLARATION
I beroby affirm that I erefrom the Conuaaah law for dw
Bumps
oli Code: Any dry of county
fallowing maven. (Saito 101.5. and e: Any c
ominBusmu
e or repair aeY structure
which w. demolish.s
a pundit to canatuic aline rd
swhpc suwmal
priorb sliarmilpalso mgo lie the for in h pcdnitu tilts
its
Ft. Floor Area
Valuation
isionaatfor
WS L1W
Sq.
(em rrisliamNOursuammthepmvisiomoftheConuactar'andPruehw(Chodia9
(commc with Scctioo ] d Code) or
of Division a of theeged
/ 0 00
marauder.
mare
and the alleged caempuan. Any violation of
H Swops therefrom and the basis My
this t estrum
APNNumber
Occupancy Type
it
io by airyapplicant forapermithabjccuNeapplkaatoacivilPenalty of
Section
not mom Nan five hundred tlallars (5300}
man
31621057.00
0Lu..rk.ttiepmperty,amy eexwithwadr.rs irsa.c
Required Inspections
ti.m .Bwines,
andthe Sim snot inwndedari-d forsalepply
to owmr of
add Profession tmcmre law does rot apply b of
and PmfcssoW Code The
rt
propertywW . dd Ire hwork h..IfamrNmseeugh his
own that such impmwmw n. (m sale IL
,Inudaimpmvexd inepro erwho am not
art not ear
t etc completion. the
no. thatbuiO buildingor i impmwmein 4 halt within o
builder,, the building year ofimprowe
en t for purpose of
builder, will have Uw Wrdcn of proving that he did not Wild m impmw for puryose of
isle.).
❑ 1, an owner of the property. am exclusively contracting with licensed cenoactan to
c tummet the project (Sec. ](144. Butincas and Professors Code:) The Caotracmrs Li-
cemse Law does not apply in an owner of property who builds ar improves thereon, and,
who contracts for such projects with a conuacunds) licensed pursuant to the Connsemr'r
Licene law.
❑ I am exemptunEa Bee . B At P C for dust mason
w v Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury arc of the following declarstione
1 ham and will maintain a Certificate ofCmuent to self-iuum far Worlan'sCompen-
sadom, as provided for by Sautn 37M of the Labor Code. for the perfnnn rose of dw
work for which this Permit is Wood.
❑ 1 have and will maintain Workers Compensation Insurance, an deputed by Section
7](Xm`din labor Codi far the pctformana ofthe work far which this permit is issued.
'
MyWmkand Policy number er
CeC�por anir.I'!1_k 44No.:
7Z
CERTIFICATE OF EXEMPTION FROM W KERS'
COMPENSATION INSURANCE
mbinscabn need mthecompluwd if the permit is foram hundred dollars ($I(d)
or less)
1 cenify Not in this performance of the work for which this Permit is issued. I Shall not
employ any person in any manoerso as b become subject to the Workers'Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, at= making this CcniRaw of Exemption, you should
bamae Subject in the Wodu ] compensation Provisions of me I2bm Code, you mLLe
' forthwith comply with such provisions or this permit shall W deemed rewkcd.
CONSm LENDING AGENCY
I.. cr0N
1 hereby aRthi the them it a lending agency for the perfurmance of
(Sec. 30
c work for which this permit s issuW (Sec. S09], Civ. C.)
' tamest
L
Lcndert Nuns
,
L<nders Adtlm.•
I unify Nu I have read this application and show Net this abow information is
coned l agree to ero ly with all city and county ordhum9ex and sew laws ml. ink to
Wildingeonhaueunn, dhemby amhmim p..a rduscitymawr.pat the
aWw-menuomd pnrad for insPecdonp a
(We) agree I..uw,'ndcmnify an harm the City of Caperton against
osts dex chmayin y'a'ayaaraagunstsoid City
in conscgoe ti B of is
I liabilitia,juJEG'
S I CO PLY WITH ALL NON-POINTIssued
/ �iA
by: Date L
�` t�'
Re -roofs
Type of Roof
Signuum of Appl on r Dam
HAZARDOUS MATERI DISCLOSURE
Will the cep loot or fueurt Wilding antoomerheadlehvaduccomorial
as dented by the Cupcnino Municipal C aptur 9.12. and the Health and Safety
Code, Section 25532(a)?
❑Yes No
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 acupant tie equipment ar devices which
..it harsrom s air canumiants u d by the Ray Arta Air Quality Mami,mcnt
all new materials for inspection.
District
❑ Year
I how re her usmawri mkits undcr ChePwr E.95af the Giifar-
niaHealdt&Saf 50 ZSumbruand thatifthe Wilding
does hatcurrent II wn 'tU ility he notify dw occupant of dwrequimmmnts
W enrwawaraaPmy.
Signature of Applicant Date
All roof coverings to be Class'W' or better
Daw-
Owner or wthan agcm
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CITY OF CUPERTINOxf
DIVISION PERMIT'
a 4 t
BUILDING
BUILDING ADDRESS:
PERMIT' NO.
10183 RIEDEL PT,
AMERICAN
PERMIT ISSUE DATE
PHO .:
A CONTROL NO.
408)436-8151
ARCHITECTlENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a a o a
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Cbapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code. and my liccme is
in full fora and effect
RMDL KTCHEN (12 0 SQ) &BTHRM (2 8 SQ) ; NO RE—RF & SOME
License Class Lic. N
Date Contncwr
STRUCTURL
ARCHITECTS DECLARATION
I understand my plans stall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 703 ", 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 saternemt
that he is Ganged 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 thc Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
00
APN Number
Occupancy TI pe
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500),
31621057 0 0
❑ L as owner of the property, or my employees with wages as their sole compersadon,
Required Inspections
will do the work. and the structure is not intended or offered for site (Sec. 7044, Business
and Professions Code: The Conuutor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sae, 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.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Set- 70K Business and Professions Code:) The Cootracwh Li-
cense Law does not xpply to an owner or property who builds or improves thereon, and.
wbo contracts for such projects with a coniractor(s) licensed pursuant to the Contractors
License Caw.
❑ 1 am exempt under Sc,_ B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate 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 Worker's Compensation insurance, as required by Section
3700 or the Libor Code, for the performance of the work for which this permit is Issued.
'
My Worker's Compensation Laurance carrier and Policy number are:
Carrier. Polity No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sccdm need not be competed if the permit Is for one hundred dollars ($100)
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 manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT; If, after making this Certificate of Exemption, you should
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.
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.)
Lentlers Name
,
Lenders Address
I certify that 1 have read this application and state that the above information is
'
correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of lhia city to enter upon Umc
above-mendoned property for inspection purposes.
(We) agree to save, Indcmniry 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 REGULATIONS.
Re -roofs
Type of Roof
Signature of ApplicanUConrnctor Dare
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hrardous marerial
as defined by the Cupertino Municipal Code. Cbapter 9.1Z and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will Um 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?
0Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and M34. I understand that if Use building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class '%g'' or better
Owner or wthorvLd agent Date