09010038CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20655 NANCY CT
STARBURST CON T CO
09010038
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OWNER'S NAME:
PERMIT ISSUE DATE
SA CONTROL NO.
PHON
rPRTTgrPTP'.Fq
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB METH
HOUSE.DEMO 1,640'
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 P fessiCode an my license is
•2S/ U �i
in full force and effecL
License Cl s Conti
Date � Contractors J- "-- {`F7
ARCHITECTS DECLARATION
I on erstan my plans shall be used as public records
�
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors 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 Ole a sighed statement
law 9
Sq. Ft. Floor Area
Valuation
' that he is licensed pursuant to the provisions of the Contractor's License (Chapter
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
1 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 penally of
APN Number
Occupancy Type
not more than rive hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q p
will do the work, and the structure isnot intended oroffered 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
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.
tense 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 Contractors
License Law.
❑ I am exempt under Sea , 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 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 C mpensation Insurance, as required by Section
3700 of thrm cc of
WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
i 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 Worker's Compensadon provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
4 CONSTRUCTION LENDING AGENCY
-13-r I hereby affirm that there is a construction lending agency for the performance of
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the work for which this permit is issued (Scc. 3097, Civ. C.)
~ Lender's Name
Lender's Address
7
I 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 stale laws relating to
~ building construction, and hereby au ore rcprescnialivcs of this city to enter upon the
above -mentioned properly for ins cti �t purposes.
(We) agree to save, inde "nif and cp h less the City of Cupertino against
nliabilities, judgmcnLs,costs an x scs w ich m in anyway accrue against said City
inconsequence or the
AZARD
Will the appl nl or u tiding occupant store or handle hazardous material
as defined by the Cupe rno Munlet pal 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.
❑ Yes ❑ No
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 defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes El No
Ihaveroadtheharardn materials requirements under Chapter 6.95ofthe Califor-
niaHeahh&SafctyCodc, 'o s 255I and 25534.Iunderstandthatifthcbuilding
mresponsiilytonotify the occupant of the l be m riot iss once