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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
10826 LINDA VISTA DR
RATTS CONSTRUCTION
09020112
OWNER'S NAME:
PERMIT L95UH DATE
PHONE:
S A CONTROL NO,
(650) 941-1544
ARCHi'IECT/ENGI VEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am It— scd under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force andeRecL
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LiceDate Class Co +' $'Z�Co�9
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ARCHITECTS DECLARATION
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1 understand my plans shall be used as public records
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Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following mason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolW4 or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed stalemcnt
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's L)e ense law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
15 0 0 0
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 (S500).
35614051 SWNSN
I, as owner of the mac m employees with wa
❑ ProPp'rY, Ywages as theta sole compensation,
.
Required teed Inspections
es
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The ContractorLicense Law does not apply to an owner of
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property who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such improvements are not intended or offered for Sala 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 or
sale.).
.
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors W-
cenSe Law does not apply to an owner or properly, who builds or improves thereon, and.
who contracts for such projects with a conuactor(s) licensed pursuant to the Contrwor's
License Law.
❑ 1 am exempt under Sec , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ore of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance or the
work for which this permit is issued.
eve and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
'
My Workers Compensation busuranee carrier and Policy number am:
4 OL 7
Carrier. Policy No.: b " r
CERTIF WE OF EREMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($LOG)
of Icss.)
I certify that in the performance of the work for which this permit is Wucd, 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 Workers Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C)
'
Lender's Name
,
Lenders Addrau
I certify that I have read this application and state that the above Information is
'
correct. 1 agree to comply with all city and county ordinances and state laws mining to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liab(lities Judgments, costs and expenses which may In any way accrue agairstsaid City
in consequene the granting of this permit.
APPWCA U ERSTANDS AND WILL LY WITH AI-1. N N- INT
_
Issued by: - /v
SOUR LATIO
HAZARDOUS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as dented by the Cupertino Municipal 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 IaJ7vo
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 IfJ'nu
_
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. i understand that If the building
does not cturcn a tenant that it (a my res W notify the occupant the
reyuiremcn
Signature of Applicant Date
All roof coverings to be Class'n" or better
Dote
Owner or authorbcd agent