09030004BUILDING DIVISION PElt1r11T 777
MIT NO.
BUILDING ADDRESS:10552 JOHN WAY TBD - O BE DETEMIT ISSUE DATE
'ER'S NAME:ITARY NO. OL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
ADD
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70()0) of Division 3 of the Business and Professions Code, a6d Mylicensc is
in full force and effect.
License Class Lat• 8
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall 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 7031.5, Business and professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
priorto its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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
Section 7031.5 by airy 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 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 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 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.).
O 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors 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 Contractor's
License Law. Q lam exempt under B & P C for this reason
Six. /
Date
x
p ATI ECLARATION
I hereby affum under penalty of perjury one of the following declarations:
I 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 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
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(MIS section need not be completed if the permit is for one hundred dollars ($100)
mr less)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any m cr so become subject to the Workcrs' Compensation
Laws of California.
Applicant
NOTICE PLI ng is Certificate of Exemption, you should
become subject to the o ompe on provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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.)
Lenders 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 aut prim 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 granting of this permit.
APPLICANT UNDERSTANDS Wl Y WITH ALL NON -POINT Lam/
SOURCE REGUL TIONS. 1710
Signatu A 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
'e, Section 25532(a)? �6/
❑ Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants u dgfined by the Bay Area Air Quality Management
District? `m=vwV(/
Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health dt Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not cumn cave a tenayf-d2t it is my responsibility to notify the occupant of the
_.....—_-_ - t-wmet mriouajuttance of a Certificate of occupancy._
ST&MAST 3RSUITE, STUDY, F6&TNk i0&nPDD
Ft. Floor Area
umber
Required Inspections
Valuation
Type
Issued b} : Date
Re -roofs -
Type of l:Oof
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 rlaterials for inspection.
Signature; of Applicant Date
All roof coverings to be Class'jW' or better
Owner or