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CITY OF CUPERTINO
BUILDING DIVISION PERIVIIT�RAQ��#Tl��
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BUILDING ADDRESS:
PERMIT NO.
10201 TORRE AVE
TBD - TO BE DETERMINED
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO.
ARCHrrECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivi n 3 of the Business and Professions Code, and my license is
in full force and effect. SS14U
COMM' L TI; EXTERIOR DOORS (REPLACE GLASS & DOORS)
License Class Lic. q '51
Date Contractor tLto GAS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 703 1.5, 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 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 Cade)ser
that he is exempt therefrom and the basis for dee alleged exemption. Any violation of
$15080
APN Number
Occupancy Type
p y yp
Section 70315 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars ($500).
36941005 .MP
❑ p petty, or my employees with wages as their sole compensation,
I, as owner of property,
Required Inspections
will do the work, and dee structure is not intended or offered for sale (Sec. 7044, Business
and Professions code: The Contractors License Law does not apply to an owner of
_
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, dee building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a coniractor(s) licensed pursuant to dee Contractors
License Law.
❑ I am exempt under Set , B & P C far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of elm following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the of the work for which this is issued
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performance permit
My Work in Policy number am:
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Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE
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(This section need not be completed if the perm it is for one hundred dollars ($ 100)
or Irst)
1 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 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 permit shall be deemed revoked.
CONSTRUCr1ON 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
"
Lenders Address
1 certify that I have read this application and state 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 authorize 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 expenses which may in any way accrue against said City
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in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCEREGU
HAZAS MATERIALS DISCLOSURE
Will the applicant um building occupant store or handle hazardous material
as defined by dee Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section25532(a)?
All roofs shall be inspected to any roofing being installed.
[]Yeso
prior material
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 hazardous air contaminants as def] d by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes u
1 have mad 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
requirements which m met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
Y}
All roof coverings to be Class " '' or better
Owner uthorizcd agent Date