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BUILDING DIVISION PEPMT
BUILDING ADDRESS:
21834 CORTE MADERA r_,N
OWNER'S NAME:
& — ---
ARCHLTECTI ENGTNELEL:
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and effect- t1
1
;.icense QChiaLdc, M U
7atc Contractor
ARCHITECCS DECLKRATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law ror the
'ollowing 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 is issuance, also requires the applicant for such permit to file a signed statement
[bathe is licensed pursuant to the previsions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
rat he is exempt therefrom and the basis for the alleged eaemptiort_ Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not morn than five hundred dollars (3500).
'L as owner of the property, or my employees with wages ss their sole compensation,
will do the work, and the structure Is not intended or offered for site (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, 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).
❑ 1. as owner of the property. am exclusively Contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contactors U-
cenae Law does not apply to an owner of property who builds or impmves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License law.
❑ i am exempt under Sec , B $ P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following ded—flons: 4have and will maintain a Certificate of Consent to self-lnsum for Workers Compea-
n, as provided for by Section 3700 of Our 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 or the Labor Code, for the performance of the work for which this permit is Issued
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 10f1)
or less_)
I ceniry that in the performance of the too k for which this permit Is issued I shall not
employ any person t tanner o}s to c subj // ecy}�a
o the Workers' Compensation
Laws of Calif a. Da -� / /I � 7
Applicant --, 1 r'
NOTICE TO AP LI . If, aficr making this Ccni icau: of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peanit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency ror the performance or
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and sate that the above information is
cormcL 1 agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorim mpresenatves of this city to enter upon the
above-mendoncd 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
in consequence ling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPOY WITH ALL NQN-POINT
bIgnature bt AppncanVkbntractor / hate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.1 Z and the Health and Safety
Code, Section 25532(a)?
❑Yes AN.
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminans as defined by the Bay Area Air Duality Management
District?
❑Yes Gt1No
1 have read the hazardous materials mquiremens under Chapter 6.95 of the Califor-
�calth&Saf Code. Secdorts 25305, 25533 and 255U4.1 understand that Uthe building
no my w a uCeant, h[ ts my lily to notify th,oceu t of the
men w must et 'or tan of
PER Mrr NO.
PERMIT ISSUE DATE
SA Y CONTROL NO.
ADD(11392SQ) MSTR BDRM&BTH,
GSTBDRM, STUDY& Job Description
Sq. Ft.
APN Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
rUILUINU FhRMIT INFO
ELECT PLUMB
uation
Date _L ( i
All roofs shall 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 of Applicant Date
All roof coverings to be Class 'A"' or better