09010104CITY OF CUPER11NU
BUILDING DIVISION PERMIT�T
` PERMIT NO.
BUILDING ADDRESS:
19620 STEVE TBD — TO BE DF2FEMThJE_D,_ "01 n1 nd
PERMIT ISSUE DATE
OWNT-61NME:
SAN CONTROL NO.
PION
BUILDING PERMrrINFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
°' z LICENSED CONTRACTOR'S DECLARATION
00
U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z r,Uj with Section 7000) of Divi ion 3 of the Business and Prof�it'na Code'
d , and my license is
a a„ in full Corer and effect i oQ
v� Z License Chais}� r ��,JJJ Lic. #
Q Datc ifContractor
tit"�' m ` v ARCHITECTS DECLAMSTION
zy I understand my plans shall be used as public records
aU
IL, Licensed Pmressionai
I y OWNER -BUILDER DECLARATION
a I hereby affirm that I am exempt from the Contractor's License Law for the
: p O following mason. (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
i " ti prior to its issuance, also requires the applicant for such permit to file a signed statement
�55 a
[bathe is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars ($500).
❑ 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 Contractor's License Law does not apply to an owner of
properly 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 Coniractoes Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contra is for such projects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
❑ I 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:
❑ 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 and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worke s Comp nsalion-I}n-suranm carie and Policy number am:
Carrier. QtaL[ S I olicyNo.: nobhi
CERTIFICATE OF EXEMPI70N FROM 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, 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: lf, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
� CONSTRUCTION LENDING AGENCY
H t�-r I hereby affirm that there is a construction lending agency for the performance of
r%' the work for which this permit is issued (Sec. 3097, Civ. C.)
w Q Lender's Name
Landers Address
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
V building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save 'n emnhfy and keep harmless the City of Cupertino against
CA liabilities 'udgments, ,co and pens,- which may in anyway accrue against said City
U in con ucnc f the g olio This permit.
APPLI A U DER TA D WILL COMPLY WITH AL NO -POINT
SOURO S
Sign ture Applicant/ an ctor V Data I
H DOUS MATERIALS DISCLOSURE
the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Code, Section 25532(a)? k-
0 Yes
❑Yes .0
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
District? %Iu
El Yes
1 have mad the hazardous materials requirements under Chaptcr6.95 of the Califor-
nia Health & Code,Se • ns 25505,25533 and 25534,1understand thatifthebuilding
docs not c nil have a man at:!\s my responsibility to madly the occupant of the
requireme w mut me nor to suance of a Certificate of Occupancy.
r
Owner of 6dzed agent Date
T.I 6628 SQ FT
INCLUDE (M, E, P) SCOP3ob Description
Sq, Ft. Floor
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy
Date
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 "{`' or better