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08060146up0 <LU C nnLa ~ � U. r0V Il % pC yea XFC CITY OF CUPERTINO DIVISION PERMIT BUILDING BUILDING ADDRESS: PERMIT NO. 1 218 SANTA CLARA AVE TBD- 7' OWNER'S NAME: PERMIT ISSUE DATE 1, S A CONTROL NO. ARCHITECT/ENGiNEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 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 is in full force and effect. ADD 21 --:SQ FOR ADD ' L BDRM&HLLWY & ENTRY, NO License Class Lic. M DateContractor STRUCTRL ARCHITECT'S DECLARATION I understand my plans shall he 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 to its issuance, also requires the applicant for such permit to Glc a signed statement License Law (Chapter 9 Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 4 O 0 (] that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number 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 (5500). 32622007 .00 ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections 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 {ak 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- cense Law docs not apply to an owner of property who builds or improves themon, and • who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License law. 01. exem under Sec.^ --- B & P C�for this reas9n "!= Date `�, '•R'S WO COMPENSA110N DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑ 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. ❑ 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 am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Chis section need not be completed if the permit is for anc hundred dollars ($100) fur Icss) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner !!I to bcc sub' fee Workers' Compensation Laws of California. — Applicant NOTICE TO APPLI : If, atUr makinilhis d6rtiricate 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 Lendees Address I certify that I have read this application and stale 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 authorise 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 j liabilities' judgments. costs 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 Issued Date by : SOUR REGULATIONS. : ___ % Re -roofs Signatu of AppUcant/Contfactoril Date I HAZARDOUS MATERIALS DISCLOSURE Type of Loof 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(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yea dpfIo If a roofs 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 defined by the Bay Area Air Quality Management all new materials for inspection. District? &o ❑ Yes 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant, that it is my responsibility to notify the occupant of the require is which must be met prior to uancc of a Certificate of Occupancy. J04-30 07 Signature of Applicant Date �`--" All roof coverings to be Class "rI{" or better _ Owner or autho ikdd agent Dare CITY OF CUPERTINO BUILDING PERMIT SATE BUILDING ADDRESS: 10218 SANTA CLARA AVE CONTRACTOR: TBD - TO BE DETERMINED PERMIT O: 08060146 OWNER'S NAME: PHONE NO: ❑ LICENSED CONTRACTOR'S DECLARATION T_ F BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # MECH RESIDENTIAL F COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 213SQ FOR ADD'L BDRM&HLLWY & ENTRY, NO (commencing with Section 7000) of Division 3 of the Business & Professions STRUCTRL 11/20/09 REVSN ANTERIOR WALL & PARTfI lON(CONVERT Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 1 have and will maintain a certificate of consent to self -insure for Worker's Compensation, 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 provided for by Sq. Ft Floor Area: Valuation: $40000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APN Number: 32622007.00 Occupancy Type: APPLICANT CERTIFICATION 1 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 authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. .� �/� .G_�—'� ' Date: Issued Signature Date �`r` 17 OWNER -BUILDER DECLARATION RE -ROOFS: I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed. If a roof is the following two reasons: installed without first obtaining an inspection, I agree to remove all new materials for 1, as owner of the property, or my employees with wages as their sole compensation, inspection. will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) Signature of Applicant: Date: I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain I have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air permit is issued. contaminants as defined b the Ba Area Air y y Quality Management District I will 1 certify that in the performance of the work for which this permit is issued, l shall maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must Owner or au orized agent: R In ) ,20 0 f �1 forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -poi t source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional