08110074CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10651 C
OWNER'S NAME:
ARCHTfECT/ENGINEER:
00 LICENSED CONTRACTOR'S DECLARATION
U 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z a with Section 70W) of Division 3 of the Business and Professions Code. and my license is
<� rn In full force and effect -
License Class Lie. 0
c3 Date Contractor
ARCHI EC1-S DECLARATION
1 understand my plans shall be used as public records
)yU
a �; Licensed Professional
O OWNER -BUILDER DECLARATION
N
� X I hereby affirm that 1 ern exempt from the Contractors License Law for the
p O following renson. (Section 703 M, Business and Professions Code: Any city or county
,��o which requires a permit to construct, alter, improve, demolish, or mpair any subtle
prior to its issuance, also requires the applicant for such permit to file a signed statement
Y < that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
t (commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
r 3 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 (S500).
❑ L as owner of die property, or my employees with wages as their sole compensation,
will do the work. and the slroctum is not intended or offered for sale (See. 7044, Business
and Professions Code-. The Contractors License Law does not apply to an owner of
properly who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements are not intended or offered for sale IL
hawever, 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.).
u owner of site property, am exclusively contracting with licensed contractors to
natroct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li.
cense Law don not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor (s) licensed pursuant m the Contractors
License Law.
❑ I am exempt under Set- , B & PC for thi reason
Owner V
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of site following declarations
❑ I have and will maintain a Certificate ofCoruent 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 sibs 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 Worker's Compensation Insurance carrier and Polity number are:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
CThis section need not be completed if the permit Is for onc: hundred dollars (S100)
or Icss.)
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 mine �Rbjgct to the Workers' Comen pation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, 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.
ti
O CONSTRUCTION LENDING AGENCY
r r-+ 1 hereby affum that there is a construction lending agency for the performance of
the work for which This permit Is Issued (Sec. 3097, Civ. C.) _
tl Q Lenders Name
4 Lenders Address
�z
Q 1 unify, that I have read this application and state that the above information is
correct- I agree to comply with all city and county ordimmm and state laws relating to
Vbuilding construction. and hereby authorize representatives of this city to enter upon the
W above -mentioned property for Inspection purposes-
(V✓c) agree W save, indemnify and keep harmless the City of Cupertino against
y liabilities, judgments, costs and expenses which may in soy way accrue against said City
7' in consequence of the granting of this pamiL
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applicant/Couractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as damned by the Cupertino Municipal Code, Chapter 9.12_ and the Health and Safety
Code. Section 25532(a)' /
❑Yes ❑.No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dSfined by the Bay Ama Air Quality Management
District?
❑ Yes ON 0
1 have mad the hazardous materials requirements under Chapter 6,95 of the Califor-
nia Health & Safcty Code, Sections 25505.25533 and 25534.1 understand that if the (wilding
don not currently have a tenant, that it ' my nobility to notify the occupant of the
requirements which must,pcc met PH tto Lc�uance a Certificate of Occ!7 . _
Owner or authorized agent agent ate
408) 655-9582
PERMI I NU.
PERMrr ISSUE DATE
S A
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
0 0
0
Job Description
NEW 2-STORY HSE,2310SQ,& GARAGE 448SQ-SANITARY IS
SUNNYVALE'S JURISDICTION.
Sq. Ft. Floor Area
ME
Valuation
APN Number Occupancy Type
37534049.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date _; L— C)A
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