07050032 777 777r77777 777777-.'.''
CITY OF CUPERTINO ��
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: TBD _ TO BE DETERMINED 07050032
10655 FLORA VISTA AVE
PERMIT ISSUE DATE
OWNER'S NAME: 1 7
MIMI PHAN & JEREMEY LE SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECI7ENGiNEER: BLDG ELECT PLUMB MECH
d Z LICENSED CONTRACTOR'S DECLARATION Job Description
0
UI hereby affirm that 1 am licensed under provisions of Chapter 9(commencing HOUSE DEMO
z E with Section 7000)of Division 3 of the Business and Professionde,and my license is
UJ
=y in full force and effect. ql
Z
License Class �RECTS
Lic.#
' Contractor C
F w Datc DECLA AT10N
I u cretadmused as publ c records
;WU
u,y Licensed Professional
O a OWNER-BUILDER DECLARATION
I< I hereby"Mim that I am exempt from the Contractor's License Law for the
p o 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 Valuation
r- rn prior to its issuance,also requires the applicant for such permit to file a signed statement c Ft.Floor Area
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �'fl $10000
i ts— (commencing with Section 70D0)of Division 3 of the Business and Prof ions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 2 6 0 8 0 2(I . V V
not more than five hundred dollars($500)
❑I,as owner of the property,or my employees with`"ages 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 Contractor's License Law docs 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 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractor's Li-
cense Law docs 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.
am exempt under Sea B&P C for this reason
❑[
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm 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.
❑1 have and will maintain Worker's Compensation insurance.as inquired 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:
0/
Cartier.
Policy No.:
"TI TE OF EXEMPTION FROM WORKERS'
OMPENSATION INSURANCE
(This section need not be completed 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,I 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 Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z� CONSTRUCTION LENDING AGENCY
H 1 hereby affirm that there is a construction lending agency for the performance of
(j. the work for which this permit is issued(Sec.3097,Civ.C.)
w QLender's Name
�Z Lenders Address
i certify that I have read this application and state that the above information is
LUL+ correct.I agree to comply with all city and county ordinances and state laws relating to
CU
building consuuction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
>" 0. (We)agree to save,indemnify and keep hannlc uy of Cupertino against
t) liabilities,judgments,costs and expenses whiph any way accrue against said City
U Z in consequence oW� Zzis
�•,�� s,: Date
►� APPLICANT UWILL COMPLY WITH ALL NON-POINT Issued b
SOURCE REGU6 Re-roonature of AppDare Type of]Zoof
ATERIALS DISCLOSUWill the applicant or future ulding occupant store or handle h ardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
❑Ycs No_\ If a roof is installed without first obtaining an inspection,I agree to remove
Will the 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 1 naterials for inspection.
District?
❑Ycs IP4.
1 have read the hazardous materials rcquircrlicnts�hapwr 6.95 of the Califor-
nia,Health&Safety Code,Sections 255g5,25533� .1 understand that if the building
does not currently have a tgpanklfiai it' responsihility to notify
the Pant n the Date
requirement,
be W,issuanccofaCcrtifsatcoI u err. Signature of Applicant
_ b r.5� O All roof coverings to be Class"B"or better
Owner or authorized agent D