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CITY OF CUPERTINO
BUILDING DIVISION PERAUT
BUILDING ADDRESS:
PERMIT NO.
10160 STERN AVE
TBD —
OWNER'S NAME_
PERMIT ISSUE DATE
S CONTROL NO.
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 13
In full force and effect 16
NEW 2 STORY SFDWL 2275_ SQFT TO LIVING AREA, 440
License CI L e. N
Date b / !JD Contractor
SQ
�ARCHftECI-S DECLARATION
I understand my plans shall be used as public records
FT ATTACHED GARAGE
Licensed -Professional
OWNER -BUILDER DECLARATION
1 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 mquiras a permit to construct, alter, improve- dcmolLsh, or repair any structure
prior to is 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
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
3 0 0 0 0 0
APN Number
Occupancy
P cy Type
Section 7031.5 by any applicant for a permit subjects the Applicant to a civil penalty of
not more than five hundred dollars (SS00).
37512006.00
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
win do the wort, and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code_ The Contractors License Law dues not apply to an owner of
property who builds or Improves thereon, and who does such work himself or through his
oven employers, provided that such Improvements are not Intended or offered for sale. if,
however. the bu iltiing or Improvement Is sold within one year of wmpletkm. the Wnrcr.
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 Lt.
cease Law does not apply to an owner of property who builds or improves tbereon, and,
who contracts for such projects with a contractor(s) Ilccri d pursuant to the Comractors
License Law.
❑ 1 am exempt under Sec , B & P C for ails reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dechradont
❑ 1 have and will maintain a Certificate of Consent to self -Insure forworlmrsCompen-
salon, 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 malmain Workct s Compensation lanrance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
My Workers Compensation Laurance carrier and Policy number are:
Carrier: t7�D r� I:�w l Policy No. GY)eg
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars (3100)
or less)
1 certify that in the performance of the work for which this permit is issued. I shall oat
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 Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peunfl shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performanceof
the work for which this permit is issued (Sec. 3097, CH. C.)
Lenders Name
Landers Address
1 certify that 1 have read this application and state that the above information is
correct I agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorise reirmsdtita0ves 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 sgaimt
liabilities, judgments. costs and expenses which may in any way accrue against said City
In consequence of the granting of this permlL
DISCLOSURE
Will the applicant or future building occupant store or handle herardoas material
as defined by the Cupertino Mumcip Code. Chapter 9.12, and the Health and Safety
Code, Section 25532U)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yee No
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 harardnm air conraminants as red by the Bay Area Air Quality Management
all new materials for inspection.
DWdct7
❑Yee No
I have read the hazardous materials rcqufmmcnu under Chapter 6.95 of the Califor-
rda Health & SafetyCmdc, Sections 25505.25533 and 25534.1 understand that if the building
does not
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