06090223 CITY C CUPERTINO
T
BUILDING DIVISION PERMIT �� TRE� '1 I1 ` RNI�N
PERMIT NO.
BUILDING ADDRESS: TBD — T J BE DETERMINED 0 6 0 9 0 2 2 3
21872 HERMOSA AVE
PERMIT ISSUE DATE
?R'S NAME:
03/16/2 07
JOSEPH YEN
SANITARY NO. CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: 2 STORY SFDWL-1ST/2 212 ' —2ND BLDG ELECT PLUMB MECH
n 0 0 0
LICENSED CONTRACTOR'S DECLARATION r _jQ1�Docription
0IZDu� !hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70(10)of Division 3 of the Business and Professions od d my license is
in full RIF
>>H force and effect
Z License CI
Dale O Contraewr '7.✓`�
i 6
u� CHITECCS DECLARA 10
j aa
< 1 understand my plans shall be used as public records
to
9L.
U.HLicensed Professional
•O< OWNER-BUILDER DECLARATION
ja 1 hereby affirm that 1 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 atter,improve,demolish,or repair any structure"n prior est its issuance,also requires the applicant for such permit to file a signed statement Sq.Ft.Floor Area Valuation
-
z1 that he is licensed pursuant to the provisions o(the Contractor's License Law(Chapter 9
t=-O (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that hempt therefrom and the basis for the alleged exemption.Any violation of
e is exOccupancyT e
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of APN Number YP
not more than five hundred dollars(5500).
FJ 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 Required Inspections
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 he did not build or improve for purpose of
sale.).
I.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 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 Contractors
License Law' B&P C for this reason
❑lam
exempt under Sec
:r Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insurc 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 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 Worker's Compensation Insu licy nu be � A
Carrie G�C7r~ /policy No.;
RTIFICCrTE OF EXEMPTION
ON ROM WORKERS'
(This section need not be completed if the permit is far 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
(~. .�. I hereby affirm that there is a construction lending agency for the performance of
(Y. the work for which this permit is issued(See.3097,Civ.C.)
w Q Lender's Name
z Lender's Address
U C I certify that I 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
Ubuilding construction,and hereby aulhome representatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
a (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
U z in consequence of the granting of this permit. Date O
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued bl,:
SOURCE REGU S. -3 6 u6C
Re-roofs
t/C0 or Type of Roof
RDOU ATERIALS DISCLOSURE YP
ZZ;
Will the app cant or fur building occupant store or handle hazardous material
defined by the Cu o Municipal Code,Chapter 9.12,and the Health and Safety
Section 25532(x)? ��, All roof: shall be inspected prior to any roofing material being installed.
❑Yea 4b< 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 cfrncd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it i's my responsibility to notify the occupant of the Date
requirements whit be metQrio ' uance foe p !y Signatur-.of Applicant
S j All roof coverings to be Class"B"or better
d a
authorizegent tc