09030223 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: 09030223
1173 CRESTLINE DR TBD - To BE DETERMINED
PERMIT 155UE DATE
JNER'S NAME:
�ftTTN �(1TrnT 4YANC" S A CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHITECrIENGINEER: BLDG ELECT PLUMB MECH
p C LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Professions Code,and my license is RMDL(E) {TCHN(2 0 0 S Q) ,C ONVRT PRT FAMRM TO 4TH
H in full force and effect
2 License Class Lie.
Contractor
BDRM&RL DCT LAUNDRY(2 3 0 SQ) ;NO RE-RF;DO HAVE
p
Date
ARCHITECTS DECLARATION STRUCTU RL
04-a I understand my plans shall be used as public records
�yU
g
U.l- Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirmthat I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and ProfeWons Code:Any city or county
K m which requires a permit to construct alter,improve,demolish,or repair any structure
y"y prior to its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
-Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $30000
xt=- (commencing with Section 70DO)of Division 3 of the Business and Professions Code)or
y
5 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($5M). L36229041 . 00
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sale(Sec.7044,Business Required Inspections
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
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-
cense Law does not ply m an owner of pro y who builds or improves thereon,and
who contracts for su4�projects with a co.,Z s)licensed pursuant to the Contractor's
License Law. B&P C/1h*.70
❑1 am exempt un�r Sea
lwner DaleORKER'S COMP NDE RATION I hereby affirm under penalty of pedu one f following dec '
0 1 have and will maintain a Certificate of Consent 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.
❑1 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 Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the form ce fib k for which this,icrmit is issued,1 shall not
employ any person i y mt so ccomc subject the Workers'Compensation
Laws of California. to
Applicant
NOTICE TO AP j"ftc iters Ce i to of Exemption,you should
become subj a Worker's Cnot n prov io s of the Labor Code,you must
Z forthwith comply with such provisions or perm t s 1 be deemed revoked.
z CONSTRUCTION LENDIN AGENCY
I hereby affirm that there is a construction lending agency for the performance of
p!r� the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
p+ Lendees Address
V 0 1 certify that I have read this application and state that the above information is
LL correct 1 agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorim representatives of this city to enter upon the
O
C) W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgmcn costs and expertscs hich may in any way accrue against said City
C)z
in
ranting oC this pe it Date
►� APPLISTANDS AND ILL COMPLY WITH ALL NO(V-P 1Issued bSOURNS. 1! d ORe-roof:Signatucontractor le 'I of Roof
HAZARDOUS M ALS DIS OSUU Type
Will the applicant or future build occupant sto or handle harardous material
as defined by the Cupertino Muni'pal ode.Chapter .12,and the Health and Safety
rode,Section 25532(a)? All roof.;shall be inspected prior to any roofing material being installed.
0 Y� 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 defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes Nu
1 have read the"6f
ls mqui cuts unr Chapter 6.95 o4Califor-
de
"th& y c ,25533 25534.1 understand that ihais my nsibility w notify the oceDate
ch o issu of a Certificate of OccupaSignatuIa of Applieant
All roof coverings to be Class'n"or better