06100210CITY OF CUPEKIINU
BUILDING DIVISION PERMITT
BUILDING ADDRESS: PERMIT NO. 06100210
21651 L I ND Y LA PERMIT ISSUE DATE
OWNER'S NAME:
NELSON DARRELL 2006
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHrMCTIENGINEER: BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(X)) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
License Class Lld• 8
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm 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 u) 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
(commencing with Section 70D0) 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 any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 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
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.).
❑ 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-
ccnse 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.
❑ I am eze pt under Sec. B & P C for this reason
OwnerDate /,
WORK�FR'S CO�f ENSA f0 ECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J 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.
❑ 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 Worker's Compensation Insurance carrier and Policy number are:
Zarier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mis 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 Calif a. Date
Applicant !- f-4
NOTI,CE APPLICANT: 1 , after i6aking 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 (Sec. 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. 1 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 to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments• toss 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
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal odc. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes o
Will the applicant or future It"
occupant use equipment or devices which
.:mit hazardous air contaminants as def by the Bay Area Air Quality Management
District?
❑ Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safety Codc. Sections 25505, 25533 and 25534.1 understand that if the building
docs nnppyy currently have a tenant. that it is my responsibility to notify the occupant of the
rcauifrlitens which must be mcLO[ipuo issuance of a Certificate of Occupancy.
or authorized
Date
Job Description
DEMO SWIMMING POOL
Sq. Ft. Floor Area
Required Inspections
Issued by:
Re -roofs
Type of Roof
500
Valuation
Occupancy Type
Date
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
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class "B" or better
Date
OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) will perform:
A. — All the work authorized by this permit
B. _ A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License #
Type of work to
t/=/ -GL
3. _ 1 will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
.....................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner -Builder Information (reverse side).
Property Owner's Signature:,,
Job Address: ZAP�-
Date: it 3D. D
Permit #
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
'off
CITV Of
"UPERTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
2/6
PER6 /0611L/
OWNER'S NAME:
PHONE # '2 S 3 - d T
GENERAL CONTRACTOR:
FAX #
I am not using any subcontractors:
Signature
ni-ml,ra161P r„1 rontractors, and complete the following information:
Date
Owner/Condactor Signature
iD. 50,0 6
Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring- Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Condactor Signature
iD. 50,0 6
Date
CITY OF CUPERTINO
.m 1 of 1 PERMIT RECEIPT OPERATOR: amyw
COPY # : 2
Sec: Twp: Rng: Sub: Blk: Lot:
APN ........: 35622015.00
DATE ISSUED.......: 10/30/2006
RECEIPT #.........: 36606
REFERENCE ID # ...: 06100210
SITE ADDRESS .....: 21651 LINDY LA
SUBDIVISION .......
CITY CUPERTINO
IMPACT AREA ......
OWNER NELSON DARRELL
ADDRESS ..........
CITY/STATE/ZIP ...: ,
RECEIVED FROM ..:.DARRELL NELSON
CONTRACTOR ........ LIC #
COMPANY ...........
ADDRESS ..........
CITY/STATE/ZIP ...: ,
TELEPHONE .........
FEE ID UNIT
QUANTITY
P24OUNT
PD -TO -DT
THIS REC NEW
--------------------
BAL
-----------------------
BPERMFEE VALUATION
----------
4,000.00
--------------------
104.76
0.00
104.76
0.00
BPLANCHK PERMIT FEE
104.76
139.80
0.00
139.80
0.00
BSEISMICRE VALUATION
3,500.00
0.50
0.00
0.50
---------- ----------
0.00
TOTAL PERMIT
---------- ----------
245.06
0.00
245.06
0.00
METHOD OF PAYMENT
AMOUNT
NUMBER
----------------- ------------
CHECK
245.06
------------------
3250
TOTAL RECEIPT
245.06
VOICE ID DESCRIPTION
VOICE
ID
DESCRIPTION
704 DEMO
CITY OF CUPERTINO wl o 2I O
,a DEMO
CUPCITY OF
ERTINO PERMIT APPLICATION FORM
Qty. if
T__ TT% FIPP nacrr+nt;nn Fee Grow
Applicaule 1 C.11 �
BPERMFEE
--"--
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