08020182 CITY OF CUPERTINO � � � I�
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
10635 CULBERTSON DR TBD — TO BE DET PERMIT I55UEDATE
'INER'S NAME:
A CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHrrBCT/BNGINEER: BLDG ELECT PLUMB MECH
Q � 0
y p C LICENSED CONTRACTOR'S DECLARATION Job Description
0u t hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
_z m with Section 7000)of Division 3 of the Business and Professions Code.and my license is ADD 4 9 9 'MA S TERBED/BATHRM,L I V I NGRM, PORCH: 8 0 'REAR
a- t
in full force and effec
j Uj Z License Class LM•8 OF
E-0
FO Dam Contractor
ARCHITECPSDECLARATION HOME,RE-IAODEL 726 'LIVING, MASTERBED/BTH. SANITARY
< I understand my plans shall he used as public records
IS SUNNfVALE' S JURISDICTION.
`O in Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Uccnse Law for the
i O o following reason.(Section 7031.5,Business and Professions Code:Any city or county
ywhich requires a permit to construct.alter,improve,demolish,or repair any structure
W prior to its issuance,also requires the applicant for such permit to file a signed statement $q.Ft.Floor Area Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
xr (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100000
y that he is exempt thetefrom and the basis for the alleged exemption.Any violadon 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($500). 37536028 . 00
0 1,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 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
;sale
J.
.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professionsmil oar improves tractons Li-
cense Caw does not apply to an owner of property P
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
B&P C for this reason
0 lam exempt und�Sec-
vner Q l U Date`2 �7
W RKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
0 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 Workees Compensation Insurance carrier and Policy number arc:
Carrier —
Policy No.:
CERTIFICATE OF E FFMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S 100)
or Ices.)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so.as to me subject to the Workers'Compensation
Laws of California.Date
Applicant 6rrt
NOTICE TO APPLICAi :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.
Z� CONSTRUCTION LENDING AGENCY
E.r��• I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lendces Name
0Z
Lender's Address
U C) re
I certify that I have ad this application and state that the above information is
V.H cotrcc.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
G0 liabilities,judgments,costs and expenses which may in any way accrue against said City r�
U Z in consequence of the granting of this permit. Date
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE RgMLAnONS.
1JS
.142-71d Re-roof; —
SignatureofApplicant/Contractor Date T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Mc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0Yes [;I-No If a root'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?
0 Yes V1 No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the Date
requiremcpa yhich must be met prior to issuance of a Certificate of Occupancy. S Ignatu 7e of Applicant
;r All roof coverings to be Class'V'or better
Owner or authorized agent Date