08100187 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
10514 FELTON WAY TBD - PO BE DETERMINED 87
OWNER'S NAME: PERMIT ISSUE DATE
S A 9 2 9 0 9 CONTROL NO.
ARCHITECT/ENGiNEER: BUILDING PERMIT INFO
., BLDG ELECT PLUMB MECH
0 � 0
q p LICENSED CONTRACTOR'S DECLARATION Job Description
v 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
y 3 ADD 4 5 6 SQ FT TO (N) BATH, ENLARGE KITCHEN
in full force and effect. Z b &
Z License Cla •N—
'"�^� nnate 1n r Contractor -r- j r� FAMILY RM 415 SQ FT TO ATTACHED GARAGE.
~ ARC ITECTS DECLARATION REMODEL
I understand my plans shall be used as public records
L Q I- Licensed Professional 2 3 4 0 S Q TO BATH & BEDROOMS
N OWNER-BUILDER DECLARATION
qqg 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i p O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
$9 which requires a permit to construct,alter,improve,demolish,or repair any structure
rn prior to its issuance,also requires the applicant for such permit to file a signed statement
X x G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y.t- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $280000
ARM 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 APN Number Occupancy Type
not Mori than five hundred dollars(5500). 35918036 . 00
0 1,as owner of the property,or my employees with wages as their sok compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Conuactors License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements am 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.).
0 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 does not apply to an owner of property who builds or improves themon,and.
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
Li=7WORKER'S
L
S 8&P or this% Date COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a certificate of Consent to self-insum 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
0 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 are: /3
Cartier �°`Aolity No.: /9/ O 9 9
CERTIFICA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section meed not be completed if the permit is for ono 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 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 must
Z forthwith comply with such provisions or this permit shall be deemed mvoked.
z'"' CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
fy,r7 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
]z Landers Address
U C) I certify that I have read this application and state that the above information is
LL t� corect.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
LL (We)agree to save,indemnify and keep harmless dee City of Cupertino against
rA liabilities,judgments.toss and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permiL Date �?
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued t'y:
SOURCE ATIONS.
%�%
,�--��� t� B Z�2�� Re-roofs
Signature of pelican T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any.Toofing materialeing installed.
ClYes O,+"'.. -is installed without first obtaini -Te
Will the applicant or future building occupant use equipment or devices which
If a roo 7 ngan inspection, �agre0o move
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? ^-✓
0 Yes LUSO
1 have read the hazardous materials mquimmcns under Chapter 6.95 of the Califor.
nia Health do Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements issuance of a Certificate of Occupancy. Si matu-e of Applicant Date
d Z f A I- o`j All roof coverings to be Class''`or better
Owner or fOttlbnzed agent / Datc