09020035CTFY OF CUPERTINO T
BUILDING DIVISION PER1V11T
BUILDING ADDRESS:
18848 L
OWNER'S NAME:
ARCHFIE.0 IENGiNEER
o 0 LICENSED CONTRACTOR'S DECLARATION
cu I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
w in full force and effect � J
ucense sass Lk. N
r Date Contractor geth,&74 (-';A u --Y
p RCHffECCS DECLARATION
us I understand my plans shall be used as public records
aV
U. Licensed Professional
H11
OWNER -BUILDER DECLARATION
t _ I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
>. prior to its issuance, also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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 arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundrad dollars (S500).
❑ L as owner of the property. or my employers 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 Contractors License Law does not apply to an owner of
property who builds or Improves thermn, and who does such work himself or through his
own employers, provided that such improvements are not Intended or offered for Mile. IL
however, the building or improvement Is sold within one year of completion, the owner -
builder will have elm burden of proving that he did not build or improve for purpose of
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 Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. , B & P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sadon, 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 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 Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION 124SURANCE
(rids section need not be completed it the pernit Is for one hundred dollars ($I00)
or Icss.)
I eetify that in the performmca or the work for which this permit is Issued, 1 shall not
employ any person in any map cr�u m subject to the Workers' Compensation
Laws or Calilo m
Applicant
NOTICE TO APPIJ : If, after making this Certificate of Exemption, you should
become subject to the orkers Compensation provisions of the Labor Code, you must
Qll forthwith comply wisuch provisions or this permit shallbedeemed revokcd-
r M
i CONSTRUCTION LENDING AGENCY
.4 ►�-n 1 hereby affirm that there is at construction lending agency for the performance of
i the work for which this permit is issued (Scc. 3097. Civ. C)
a Q Lender's Name
4 2 L.cnders Address
I certify that I have read this application and sate that the above information is
►-n correct I agree to comply with all city and county ordinances and state laws relating to
building ennstnnction, and hereby authorize representatives of this city to enter upon the
y W above -mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless; the City of Cupertino against
yliabilities, judgments, costs and expenses which may in any way accrue against said City
'7 in consequence of the graining of this permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RE TTONS
217 Pig
Signature of pp ran nuactor Dam
OUS MATERIALS DISCLOSURE
Will the app t or future building occupant store or handle hazardous material
as defined by the C no Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑Yes X10
Will the applicant or future building occupant use equipment or devices which
emir hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes X14o
1 have read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health &Safety Code, Sections 25505.25533 and 25534.1 unders and that if the building
does not cur inky have a tenant. that it is my responsibility to notify the occupant of the
rcqu which rotas be met prior m issuance a Certificate of Occupancy
_ ,) x2z it/�/
ADD 560 SQFT
GARAGE, DEMO
KITCHEN, 45
Sq. Ft.
PERMrr NO.
PERMIT ISSUE DATE
A
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
Job Description
BEDRM, LIVIN,
1 CAR GARAGE.
SQ FT TO BATH
426 SQ FT TO NEW
REMODEL 178 SQ FT TO
INCLUDES STRUCTURAL
Valuation
APN Number Occupancy Type
37515018.00
Required Inspections
Issued by: A
Re -
Type of Roof
Date "/ 7� ~ (/
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
A]1 roof coverings to be Class'.' or better
Dam