07030036CITY OF CUPERTINO
IT+ORINF(lRMA N
BUILDING DIVISION pFt jRMI
BUILD N D ESS:
iff CRESCENT CT LOT 2
KELLY GORDON DEVELOPMENT
PERMIT NO.
07030036
OWNER'S NAME: —
CORP
PERMIT ISSUE DATE
KELLY GORDON DEVELOPMENT CORP
12241 SARATOGA - SUNNYVALE
05/03/2007
PHONE:
DT\
SANITARY NO. CONTROL NO.
(408)873-8774
ARCHITECr/ENGLNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Codc.and my license is
S FDWL- 2 STORY 3,826' GARAGE 6741 1ST
in full force and effect 3 1
ue.N 1
Licen�.,lans
FLR: 2,433 2ND FLR: 1,393
DateContractor l
ARCHITECTS DEC ON
I uused as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from tjtc Contractors License Law for the
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
prior to its issuance, also requires the applicant far such permit to file a signed statement
the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of
$858179
(commencing with Section 7000) of Division 3 of the Business and Pro(essinns Code) ur
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 2 617 0 9 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofN
not more than rive hundred dollars ($500).
.6?
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
(1
will do the work, and the structure is not intended oroffered for sale (Sec.7044.Business
and Profusions Code: The Contractors License Law does not apply to an owner of
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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors 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.
❑ I am exempt under Sec. , 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 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
❑ 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 CCoom.�g}- ens ation Insurance carrier and Policy number are:
Carrier. S t"'�� ✓L Polity No.: 0q 7
CERTIFICATE O EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(rhit 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
forthwith comply with such provision or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Lender's Name
,
Lender's Address
1 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
building conswction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
liabilides,judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date r6;;-7
SOUR L NS
Re -roofs
'
Type of Roof
Si ore of Applic VContractor Date
HAZARDOUS MATERIALS DISCLOSURE
ill the 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)?
❑ Yes e
All roofs shall be inspected prior to any roofing material being installed.
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 materials for inspection.
District? `
F1 Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Section 25505.25533 and 25534.1 understand that if the building
docs not cu5 have a tenant. that it is my responsibility to notify the occupant of the
reyui nes wh' must be mel prior to issu a fieau: of Occupancy.
ignature of Applicant Date
- — d
All roof coverings to be Class "B" or better
Frim Dried accnt D tc