060802460 F
1
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
. . .... 77
BUILDING ADDRESS:
SHEPHERD CONSTRUCTION CO
PERMIT No. 06080246
10592 JOHNSON AVE
OWNER'S NAME:
PERMIT nUE DATE
630 PALM IT.
in/ii/2nne
PHONE:
SANITARY NO. CONTROL NO.
(650)575-4156
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effecm
7/q7/0
SFDWL 20691 -1ST FLOOR 1303',2ND FLOOR 7661,
License Class. I ILI�> Lic. #
Date �,�Contractor
GARAGE 400' -SANITARY IS SUNNYVALES JURISDICTION
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirin that I am exempt from the Contractor's 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 It) 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
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
�466083
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
0 1, as owner of the property, or my employees with wages as their sole compensation,
Required nspections
will do the work, and the structure is not intended or offered for salt (Sec. 7044, Business
and Professions Code: The Contractor's Lice= 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 age. 11.
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
salt
C3 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 -
cerise 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.
0 1 am exempt under Sec. B & P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
C] 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 Compensation Insurance carrier and Policy number am:
Carrier-. 6�mvop r _ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars ($100)
or less.)
I certify that in the perform f the workor Permit is issued. I shall not
c per"
em -ploy any person in any m r so as b r b' Workers'
ct to YWor/k0enon
*Ii
Lawsof California. Date
Applicant
NOTICE TO APP CAM: 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 provisions 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 ( cc. 3097, Civ. C.)
Lender's Name
Lender's Address
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
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree 10 save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERF
S
HAZARDOUS MATERIALS DISCLOSURE Date
Will the applicant or future building occupant state or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code,Section 25532(a)?
0 Yes v<
All roofs shall be inspected prior to any roofing material being installed.
If a roof Js 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?
0 Yes FrN.
I have read the hazardous materials requirements under chapter 6.95 of the Califor-
nia Health & Safely Code, SCCUORS25505,25533 and 25534. I undcrstard that ifthe building
does not currently have a tena 4 that it is my responsibility 10 notify the occupant of the
requir
7c agent Date
-M