09020018BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10460 BAYWOOD DR
OWNER'S NAME:
ARCHITECT/ENGLNEER:
u p p LICENSED CONTRACTOR'S DECLARATION
U 1 herebyaffirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(10) of Division 3 of the Business and Professions Code, and my license is
y in full lose and effect
j Z License Class 3 Lic• N Ia
y a Date Contractorp
ARCHITECTATION
S DECLAR
I understand my plans shall be used as public records
DWU
Oen Licensed Professional
rn OWNER -BUILDER DECLARATION
rye I hereby affirm that 1 am exempt from the Contractor's License Law for the
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in O following reason. (Section 7031.5, Business and Professions Code: Any city or county
t m ff which requires a permit to construct, alter, improve, demolish, or repair any structure
+a Z y 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
Y[- $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y .. that he is exempt therefrom and the basis for the alleged exemption. Any violadan 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 far sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs 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 ate 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.).
❑ I, 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.
cense Law docs not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sea. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
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have and will maintain a CeniBcate of Conscnt to self -insure for Workces Compen-
..._on, 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 Compe ation Insurance carrier and Policy number are:
Cartier. 7 « I -�— PolicyNo.: Z d (93 04
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 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, 1 shall not
employ any person in any manner so as to become subject to the Workcrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you mast
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. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim 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 a nscs which may hn y way accrue against said City
in consequence of the grantin this permht
APPLICANT UNDER DS AND COMPLY WITH Al L N -POINT
SOURCE R_16-11 A S ��
Signature of Applicant/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous material
as defined by the Cupertino MuniEjUalRodc, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
Will the applicant or future buildi _pant use equipment or devices which
t i,arardnus air contaminants as ed by the Bay Area Air Quality Management
.-Jct?
❑ Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
nia Health & Safety Cade, Sectio 25505,25533 and 25534. [ understand thatif thc building
docs not currently have a t, that it is ponsibility to notify the occupant of the
requiremcn hich m met ' issuance of a Certificate of Oce
Z
Owner or authorized agent Date
RPLC WATER HTR
Issued by:
Re -roofs
iq. Ft. Floor Area
APN Number
Job Description
Required Inspections
Valuation
"type
Type of R )of
All roofs , hall 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 )f Applicant
Date
All roof coverings to be Class ".. ' or better
PERMIT NO.
PERMIT ISSUE DATE
SA
CONTROL NO.
BUILDING PERMIT INFO
BLDG
ELECT
PLUMB
D
D
D
Job Description
Required Inspections
Valuation
"type
Type of R )of
All roofs , hall 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 )f Applicant
Date
All roof coverings to be Class ".. ' or better
_ CITY OF' CUPE.RTINO
.`I'AA.TER BEATER
My OF
CUPERTINO PERMIT APPLICATION FORM
APN #
Date:
Building Address:
h Lt �C
Owner's Name:
Phone #:
j 1 ; I j
Contractor:
Phone #: 6 (- 15q - ? 13 1
.Wor-dahle WaW Idea+erl
Fax #: (Pbl - IS -q - 9SS�
Cupertino Business License #:
Contractor State License #:
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6�-7 3 6 9
Contact:
Phone #: 10 4 - s9. 0S-4, o
Scofi-t- (_i¢- Ie -Field
Fax #:
Building Permit Info:
Bldg ❑ Elect. ❑
Plumb Mech ❑
Residential Nf
Commercial ❑
Job Description:
Strapped On Platform ❑
Bonded New Location ❑ Replacement �f '
Valuation:
(�C�c
Green Building Check must be completed and attached to this application.
Green Building Points achieved:
¢}
CITY OF
-UPEkTINO
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone (408) 777-3228
Fax (408) 777-3333
Building Department
JOB ADDRESS:
C) Y60
PERMIT #
00 -
OWNER'S NAME: wes1-aa u N
PHONE
GENERAL CONTRACTOR: q
FAX #
I am not using any subcontractors:
21 0
Signature Date
Please check applicable subcontractors and complete the following information:
Owner/ Contractor Signature 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/ Contractor Signature Date