09020020 CITY OF CUPERTINO
BUILMING DIVISION PERMIT
BUILDING ADDRESS: PERMrr NO.
10962 SWEET OAK ST AFFORDABLE WA
OWNER'S NAME: PERMIT ISSUE DATE
'7NE: SAAA� CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
RPLC WATR HEATER BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirmshat I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
IRA! in full force and eff 2 6
t�Z Liceb Lic.N
nse 1 7
Date Contractor A A
F ARCHITECTS DECLARATION
v
U I understand my plans shall be used as public records
L m0 H Licensed Professional
n, :s OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
is G O following reason.(Section 7031.5,Business and Professions Code:Any city or county
9 which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
H (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 violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500} P Y YP
❑I,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 for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
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
sale.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense 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 under See. B&P C for this reason
Owner Date
WORKER'S COMPENSATION 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 Workers Compen-
_.tion,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 Workers 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 Compe�anon Insurance carrier and Policy number are:
Carrier.'7L v--19�"' Policy No.-706708'70'5
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or 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 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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
pi •�+ the work for which this permit is issued(Sec.3097,Civ.C.)
Lenders Name
Z Lenders Address
U I certify that I have read this application and state that the above information is
LLL►' corrccL 1 agree to comply with all city and county ordinances and state laws relating to
0 E"' building construction,and hereby authorize representatives of this city to enter upon the
>4 a above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
o.4 Cn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
t"t APPLICANT UND STANDS AND COMPLY WITH ALL7N POI Issued by: Date
SOURCE RE / L (/ l/
Z Re-roofs
Signature of Applicant/Contractor Date —
HAZARDOUS MATERIALS DISCLOSURE Type of Rc of
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
Cole,Section 25532(a)? All roofs s call be inspected prior to any roofing material being installed.
❑Yu o
Will the applicant or folate building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
lit hazardous air contamina;xsed by the Bay Area Air Quality Management all new materials for inspection.
,strict?
❑Yes
1 have toad the haza o serials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Codc, ns 25505,25533 and 25534.I understand that if the building
does not currently ha nanL y responsibility to notify the occupant of the
require it whit ust he riot issitance of a Certificate of u
[G,' p Signature c f Applicant Date
Owner or au .cd agent Date
All roof coverings to be Class" "or better
CITY.'OFCLAP �'RTIN0
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� } . AVATUR HEATER
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` CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
Owner's Name: Phone #:
Contractor: Phone #: (,to/- 15q - 7 1 3 1
igffordahle. Weer �2a��rS
Fax C (bl - ls-y - 9SS6
Cupertino Business License #: Contractor State License #:
Contact: Phone #: (,6 - jw j, 0 S4,o
Scofit Li- fileFielcl
C Fax #: (ofol -aS�1 - 9SSb
Building Permit Info:
Bldg ❑ Elect 19- Plumb Mech
Residential Nf Commercial ❑
Job Description:
Strapped N On Platform ❑ Bonded New Location ❑ Replacement
Valuation: cl
Green Building Check must be completed and attached to this application.
Green Building Points achieved: