06100218 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ±��NI� CTCIR IQRMTI�N•
BUILDING ADDRESS: PERMIT NO.
10161 HILLCREST RD TBD - TO BE DETERMINED 06100218
OWNER'S NAME: PERMIT ISSUE DATE
PETER KO
)NE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!0 p LICENSED CONTRACTOR'S DECLARATION Job Description
U F I hereby affirm that I am licensed under provisions of Chapter 9(commencing
:Z with Section 70()0)of Division 3 of the Business and professions Code,and my license is NEW SF.
DWL: 1ST FLOOR 19631 , 2ND FLOOR 1528 ' ,
t H in full force and cffecL27
y 3 License Cl Lie.if I 7 GARAGE 616 ' , DECK (C) 817 ' TOTAL
Contractor
Dam ARCHITECTS DEC A GARAGE 5 6 .3 8 x 616 = 34730 . 08
UJ V 1 understand my plans shall be used as publicy
a
a H Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
00 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
u Zyy prior to 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 Sq.Ft.Floor Area Valuation
rFs (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $814558
L that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of t �l Number Occupancy Type
not more than five hundred dollars(5500). 32616052
V V
0 1,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 (1 p
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.).
0 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 does not apply to an owner of property who builds or improves thereon,and. S�
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's ^�
License Law. C
1 am emprunder Sec: _,_;. ,B&P C fa is ason v /.
Ow 3.. r C .... _ _—
� Date 7
orj5pS ON DECLARATION
r
1 h rebyafTirmdtndor-penalty of perjury one of the following•deelarations:
L]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 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 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)
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 Califomia.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
Oforthwith 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
p4 .� the work for which this permit is issued(See.3097,Civ.C.)
QLender's Name
z Lender's Address
U C I certify that 1 have read this application and state that the above information is
Lt . correct.I agree to comply with all city and county ordinances and state laws relating to
Jbuilding construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rFt 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
—+ APPLICANT UNDERSTANDS AND WILL MPLY WITH ALL NON-P INT Issued by:
SOU REGULATIONS.
' '► S ° 7 Re-roof:,
S urc Iicanttqtfbuiactor Date
H,61.dRDOUS MATERIALS DISCLOSURE Type of Roof
W"c 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
Code,Section 25532(a)? All roof;shall be inspected prior to any roofing material being installed.
0 Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes (11 No
1 have read the hazardous materials requirements under Chapter 6.95 of Use Califor-
nia Health&Sarely Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
require which st el prior issuancco(a ficatcofocc aney. Signature of Applicant Date
j /�
All roof coverings to be Class "B"or better
der or out riz gent Date