09030007OZ
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CITY OF CUPERTINO
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BUILDING DIVISION PER -NUT
BUILDING ADDRESS:
PERMIT NO.
21011 GREENLEAF DR
D & D CONSTRUCTION
:
S CONTROL NO.
(408)666-5298
ARCHITECTIENCINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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 Pmfcssions Code, and my license is
in full force andeffat.
REVISION: ORIGINAL PERMIT # 07120178
s< aria ��7/�v1 7�C
C w U
,REPLACE
P S L
Date u°anor
ARCHITECTS DECLARATION
1 undersand my plans shall he used ss public records
3 1 / 2 X 16 FLOOR JOIST WITH (2) 16 " TJ I 230, OVER
Licensed Professional
THE FAMILY ROOM & KITCHEN
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason (Section 7031.5, Business and Professions Code: Arty city or county
which requires a permit to construct, alter. improve, demolish, ar repair any sucture
prior to its issuance, also requires the applicant for such permit to fit a signed sutcmcot
Ft. Floor Area Valuation
that he is licensed pursuant to the provisions or the Contractors License Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 0 0 0
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 dollara (33Wl
3 2 6 0 8 0 5 6.00
❑ L 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. 70", Business
Required Inspections
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
salt.).
❑ L as owner of tlx: property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractors L-
cc= Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such pmjects with a contractor(s) licensed pursuant to the Comra es
License Law.
❑ 1 am exempt under Sec . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1Its ve and will maintain a Certificate of Consent to scif-insure for WorkeesCompen-
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 performance of the work for which this pewit is issued
'
My Worker � rep nsa . lnsuran a carrier and Polity number uc:,O
C41(
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FRO W ORKERS'
COMPENSATION INSURANCE
07rLs sccdo t need rut be completed if the permit is for one hundred dollars (3100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall Dot
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of Califomia_ 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 pecmiL shall be deemed revaked
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.)
L.endces Name
,
Lenders Address
I I certify that 1 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 eo save, indemnify and keep harmless the Guy of Cupertino against
j liabilitles,judgmems, costs and expenses which may in any way accrue against said Guy
' in consequence of the granting of this PermiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE,ULATIONS.
11e _ 13
—I
Re -roofs
SI of Applies t/Con�� Date
HAZARDOUS MATERIALS DISCLOSURE
—
Type of Roof
Will the applicant or future building occupant store or handle hrzardom material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
c«le, section 25532(a)7
❑ Yes No
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air conumunanls as defined by the Bay Area Air Quality Managcmem
all new materials for inspection.
D suict7
&No
❑ Yes
1 have toad the hazardous materials requirements under Chapter &95 of the Califor-
nia Health& Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently hale a lemur. that it is my responsibility to notify the occupant of the
mqu which matt be met prior to issuance or a Certificate ofOccupancy.
Signature of Applicant Date
"Z'��
All roof coverings to be Class'n' or better
Owner ir authorized agent Dar