06040165 CITY OF CUPERTINO 7777777777777
BUILDING DIVISION Pg,R � ���
BUILDING ADDRESS: KORET FOUNDATION PERMIT NO.0 6 0 4 016 5
20975 VALLEY GREEN
OWNER'S NAME: PERMIT ISSUE DATE
KORET FOUNDATION 2006
PHONE: SANrrARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
'Z LICENSED CONTRACTOR'S DECLARATION
'o Job Description
�F- 1 hereby affirm that I am licensed undo provisions of Chapter 9(commencing
U with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
y in full force and effect BALCONY GUARDRAIL REPAIRS & POOL ENCLOSURE FENC
{? License Class Lic.p
jZ Daae Contractor
Lu
ARCHITECTS DECLARATION
-' I understand my plans shall be used as public records
IV
F' Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
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 $79905
:14 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
g (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
._ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of r Occupancy Type
not more than five hundred dollars($500).
❑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 forsale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q 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.).
C�•�owner of the property,am exclusively contracting with Ocensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U.
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a comm-actor(s)licensed pursuant to rhe Contractor's '
License Law.
❑1 am tuner ] r ,B&p C Jor tit reason
Owner Dale
WORKER'S COMPENSATI N E RATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 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.
❑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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ubis section need not be completed if the permit is for one hundred dollars($100)
or Icss)
I certify that in the performance of a work for which this permit is issued,1 shall not
employ any per n man a n a y o c c subject Workers'Compensation
Laws of Calif ia.! a c
Applicant
NOTICE TO PPLICANT:1f,of e making this 'heats of Exemption,you should
become subj m the Workees Compensation p isions of the Labor Code,you must
Z forthwith comply with such provisions or thispcJJn shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
�r 1 hereby affirm that there is a concoction lending agency for the performance of
> the work for which this permit is issued(Sec 30997,Civ.C.)
QLender's Name ,
Z Lender's Address
I certify that 1 have read this application and state that the above information is
►' correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorise representative of this city to enter upon the
W ahove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expermes which may in any way accrue against said City
Z in consequence of the granting of this permit. f�G
h— APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date J
SO EE TIONS.
Re-roofs
Sig ture of ApplicanUComracior Date
HAZARDOUS MA ALS DISCLOSURE Type of Roof
Will to applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municip I Code,Chapter 9.12,and the Health and Safety
Code,scction25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
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?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the building
does not currelctu
ant.that it is my responsibility to notify the occupant of the
mquirem et p'r issu a ofaCcnificane of cnp cy. Signature of Applicant Date
owne orauthor(-redagcnt Date All roof coverings to be Class"B"or better