07040098BUILDING DIVISION PERMIT "MRA3MV
1
PERMIT NO,
BUILI!46MESS: 1 07040098 1 10166 MANN DR TBD TO BE DETERMINED I
PERMIT ISSUE DATE
OWNER'
06/28/2007
SANITARY NO. CONTROL NO.
z LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions or Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class _ Lic. #
Date Contractor
W ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Ec_
,n,,d Nofes;1ori-I
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
0 following reason. (Section 703 t.5, Business and Professions Code: Any city or county
0! 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 rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
o (commencing with Section 7000) of Division 3 of the Business and Professions Codd) at
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
act more than five hundred dollars ($500).
Q,
I I, as owner of the property, or my employees with wages as their sole compensation,
w III do the work, and the structure is notimended or offered for sale (Sec. 7044. Business
and Professions Code, The Contractor'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 sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that be did not build or improve for purpose of
sale.).
C] L as owner of the property, am exclusively contracting with licensed contract= to
construct 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 projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
am exempt under Sec, B & P C for this reason
Owner
Date /?nel,>7
W(§ EWS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaratiorm
I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 1 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 Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
ar truss.)
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 t)ccome subject to.ft—workiurs, Compensation
Laws of California D
Applicant — �v
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.
C
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
> ft work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Z Lender's Address
1 certify that I have read this application and suite that the above information is
correct. I agree to comply with all city and county ordinances and state laws miming to
building construction, and hereby authorize representatives of this city menter 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
Z in consequence of the granting of this; permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applicant/Contractor Dallis
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Murpcipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? 'I
[] Yes '0 No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants
defined by the Bay Area Air Quality Management
District?
0 Yes 10 No
I have read the hazardous materials requirements underChapmr6.95 of the Callifor-
maHcalth & Safety Code, Sections 25505.25533 and 25534. I understand thatifthe building
does not currently have a tenant, that it is my responsibility to notify the occupant Of the
requirement', �Whichust be met r to issuance of a Certificate of Occupancy.
0
Own
L�
er or diner agent
BUILDING PERMIT INFO
SFDWL-TWO STORY 3,167'PORCH I BLDG ELECT PLUMB MECH
..---JG)b Description
Sq, Ft. Floor Area
Required Inspections
Issued
Re -roofs
Type of Roof
Occupancy
LOS
�a
All roofs shall be inspected prior to any roofing material being installed.
n.,
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature oflApplicant Date
All roof coverings to be Class "B" or better