060401660
CITY OF CUPERTINO
BUILDING DIVISION P�'I,RI
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KORET FOUNDATION 1WPERMIT
BUILDING ADDRESS:
NO. 06040166
20800 VALLEY GREEN D
OWNER'S NAME:
PERIM ISSUE DATE
KORET FOUNDATION
006
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
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 effect.
BALCONY GUARDRAIL REPAIRS
License Class Lic. A
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's Liccnse Law for the
fallowing 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
$45480
prior to its issuance, also requires the applicant for such permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq.
(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
r
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 ($500).
❑ 1• as owner of the property, or my employees with wages as their sole compensation.
Required actions
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
9 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 We. 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.).
[j-S;'Ss�owner of the property, am exclusively contracting with Bcmised contractors to
construct the project (Sec. 7044• Business and Professions Code:) The Contractor's Li.
cease 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.
❑ 1 am exempt
RATION
I hereby affirm u�one of the owing declarations:
❑ 1 ham and will maintsent to self -r for Workers 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 EXI.TMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section Med not be completed if the permit is for one hundred dollars ($100)
or lass.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any man r he time sub'c t to the Workers' Compensation
Laws of Califs .
Applicant
NOT]CE 7.O APP 1 A foci ma ting this Citiqcatc of ExcmpGon, you should
become subject to the Workers Compensation provi ' n of the Labor Code. you must
forthwith comply with such provisions or this permit shall be deemed rcwked.
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.)
-
Lendees Name
Lenders Address
I certify that I have read this application and state that the alcove information is
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correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby autharim 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, costs and expenses which may in any way accrue against said City
in eonsegtnence of the granti of this permit
APPLICANT NDERST DSA D WILL COMPLY WITH ALL.NON-POINT
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Issued by: Date - �— V
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S U , RE ATIO 61�L j_(�7
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Re -roofs
Type of Roof
Si ature of App canVContm r Date
HAZARD US ATERIALSDISCLOSURE
Will the applicant or fut rc b 'ding occupant store or handle haym'dous material
as defined by the Cupertino Mu copal Code, Chapter 9.12• and the Health and Safety
Code. Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
3ye, e<.—
prior
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 dcftncd by the Bay Arca Air Quality Management
all new materials for inspection.
District?
Nu
[:3 Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &
thponsibility to notify the occupant of the
reyui m jw pan .
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Signature of Applicant Date
All roof coverings to be Class "B" or better
Ownor "
authorized agent Datc