07090169 CITY OF CUPERTINO `
BUILDING DIVISION PERMIT �;���� ���� ���������*: '
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BUILDING ADDRESS: PERMIT NO.
7894 BELKNAP DR TBD - Tc� BE DETERMINED 07090169 �
PERMIT LSSUE DATE
dER'S NAME:
SOUZA KENNETH A AND MARY D 10 22 2 7
SANITpRY NO. CON"CROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECI'/ENGiNEER:
BLDC ELECT PLUMB MECH
� � � �
i p � LICENSED CONTRACTOR'S DECLARATION IOb DOSCrIptlOfl
; v� 1 hcrcby affirm that I am liccnxd unAcr provisions of Chaptcr 9(commencing
; y� with Sccdon 7000) ot Division 3 af ihc Busincce and Pratcssions �, and my licensc is REMOVE (: �) WALL ; NEW FOOT I NG S( 2) & NEW P S L HDR BM
!= y in full Caree and cffect ��
� v� Z Licen �Class L�. � ,
p Datc�� % - _ Conu
: � � �— ARCHITECI'S DE LARATION
i� a
a I undcrswnd my plans s6all bc uscd as public reconLs
>yU
° u. y Licensed ProCcssional
� � < OWNER-BUIL.DER DECLARATION
j<� 1 hcrcby alTirm t�at 1 am excmpt trum ihc Contracmrs Liccnsc Law for tfic
. p O foltowing rcason. (Scction 7(Y! I.S, Business and Profcccions Codc: Any city or county
�,° � which rcquires a pertnit to conswct, alur, impmvc, dcmolish, or rcpair any swcwm
�" N prior ui i�t iscuancc, also rcquires thc applicant for such permit to filc a signcd sia�emcnt Valuation
=? a that hc is licenscd pursuant to �hc provisions of ihc Contracmr's Liccnsc Law (Chap�cr 9 ; iq. Ft. Floor Area
{[�_- �(commencing with Secdon 7000) of Division 3 0[ ihe Business and Professions Code) ar � 5 � 0 0
��.. that he is exempt there(rom and ihe bazis Cor the ailegcd exempdon. My violation o[
Section 703I.5 by any applicant tor a permit subjec�s �he appiicant to a civil penalcy o( Number Oeeupancy Type
not moce than five hundrcd dollars (5500). 3 6 2 1 � � 3���
❑ I, as owncr of tl�e property, or my employces with wages az the'v sulc compensaUon,
will do thc work, and �he suuau�e is not intendcd or offeced for sa� (Sec.7044, Business Required Inspections
and Profeuions Code: The Contracwr's License Law dacs not apply to an owner of
propeny who builds a improves thercon, and who does such wort himulf or through his
awn employccs, providcd that such improvemenls are not in�ended or ottered for sale. I(,
howevu, the building or improvement is soid within one year oC compledon, the owner-
builder will haw �he burden of proving Wat he did nat build or improve Cor purpose of
salc.).
❑ I, as owner of the property, am exctusively contrac�ing wilh licensed rnnvactors to
construct the project (Sec. 7044. Business and RoCessions Cade:) The Comrxtor's Li-
ccax Law docs not apply lo an owner af propeny who builds or improves Weceon, and ,
who conuacts for such pmjecLS with a comractor(s) li«nsed pursuant to the Convactor's
License Law.
' 1 am uempt under Sec . B& P C for this rcason
AI1W De1G
WORKER'S COMPENSATTON DECLARATION
I hercby �rto under penalry of pe�jury onc a( �he following declaratians:
I hsve and will maintain a Certi6ca�e o( Consent to scif-insure for Worker's Compen-
sation, as providcd for by Section 3700 of the Labor Code, for the performance aC thc
work for whieh this pertni[ is issucd.
❑ I have and will maintain Workcrs Compensatian Insurance, as rcquired by Scction .
3700 oC �Ac Labor Code. Cor the perCormance o( the work for which �is permit is issued.
My Workers Compensation Insurancc cartier and Policy number are:
Cartier. Policy No.:
CERT[F7CATE OF EXEMPI'[OIV F[tOM WORKERS'
COMPENSATION INSURANCE
(This scction necd not bc completcd if the pecmit is foronc hundrcA dollars (5100)
or Icss.)
I ceniCy thxt in thc performanec of thc work for which Wis permit is issucd, f shall not
amploy any pc m om ' ct�thc Workers' Compcnudon
Laws of Ca ' r '
Applicant
NOTICE TO APPLICANT: If, aftcr making ihis CcrtiGca�e of Ezemption, you shouW
bccome subjcct to �hc Workcr's Compcnsation provisions of �c Labor Codc, you must
� O for�hwiih comply wi�h such provisions or tMis pecmit shall bc dccmcd revokcd.
Z "'' CONSTRUCTION LENDING AGENCY
[-�r ►�-� I herchy aCfirm that �cre is a conswction Icnding agcncy for thc {xrfurmanix o[ .
�(, � ihc work fur which this pertnit is issucd (Scc. 3097, Civ. C.)
W Q Lcndcr's Namc .
a Z L.cnder's Address
U � l certiCy ihat 1 havc rcad this application and statc �hat �hc above infortnatiun is
��-' corrcct. I agree to comply with all ciry and county onfinancea and sute Iaws rclating io
� U building conswction, and hcreby authori�e rcprescntativcs of this city to cntcr u{xm �hc
� W ahovc-mcntioncd propcny for inspcc�on purposes_ .
a (Wc) agree to save, indcm�ify and kccp hartnlest Ihc Ci�y of Cupertino against
�� liabiliues, judgmcn�s, cosis and expenscs which may in any way accruc agains� said City
V Z in consequcnce oC the granting of this permil. 2
� AP ANT UNDERS7AND D OMPLY WITH ALL NON-POINT Issued by Date � - E/�
ATiONS „ /.
�/ l? 2�� Re-roofs �'��
Signaturc of ApplicanUConuacwr �a� T e of R oof
HAZARDOUS MA7ERIALS D[SCLOSURE }�p
Will ihc applicant or Cutwc building acupmt storc o� handtc harardous ma�crial
icCincd by Um Cupertino Municipal Codc. Chap�cr 9.I2, and �he Health and Sa(cty
�� Scction 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
p v� �+-'. ,
wll thc applicant or future building occupant usc eyuipmcnl or dcviccs which
If a roof i� installed without first obtaining an inspection, I agree to remove
cmit harardous air con�aminan�s az dcfincd by the Bay Arca Air Quality Managcmcn� all new rr aterials for inspec*ion.
��su���?
❑ Ycs �-
1 havc rcaJ ihe haiarC<ws ma�crials rcquiremcnl� undcr Chap�cr 6.95 of U�c Califor-
nia H Safcty Codc, Sccuont 25 25533 d 25534.1 undcrsund �hat if ihc building
n avc a tcnan t' pons�A' w UCy thc occupant nf �hc
rc � a w ch musi be i i ance of��o�.9�cyP . Signature of Applicant Date
(% G4 All roof coverings to be Class "B" or better
Owncr or authori agcnt Datc