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CITY OF CUPERTINO
NOW
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMrr NO.
21885 MCCLELLAN RD
TBD — TO BE DETERMINED
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OWNER'S NAME:
PERNM ISSUE DATE
9
A CONTROL NO.
ARCHITECIfENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lion
lob Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
S3 �/ P
with Section 7000) of Division 3 of the Business and Professions Codc, and my license is
in full farce and effect
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2 STORY •4�63 9 -' S FDWL W /ATTCH GARAGE 4 31 ' & 7 5 0 S Q
License Class Lic. s
Date Contractor
PORCH&CARPORT—FIRE SPRINKLERS REQUIRED.
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
9
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. Alta. improve, demolish• or repair any structure
.
prior to its issuance, also requires the applicant rot such permit to file a signed statement
ucenac Law (Chapter 9
Sq. Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the.Contraclor's
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
9 0 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031.5 by arty applicant for a perch subjects the applicant to a civil penalty of
APN Number Occupancy Type
not more than five hundred dollars (S500).
37514008 .00 .
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 car offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
properly 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. ir,
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.).
I• m owner of the properly, am exdusively contracting with licensed contractors to
cohstruct the project (Sec. 7044, Business and Professions Code:) The Contracmes U.
cerise Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a eoninetor(s) licensed pursuant to the Contractor's
License Law.
❑ I am ex t udder Sec. , B & P C for is reason
r a
Owner -� �.( .Date
of the following declarations
1 hsve and will maintain a Certificate of Consent to self -Insure for Worker'sCompcn-
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 artier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if ciao permit is foronehundtc0 dollars (S 100)
or less.)
I cunifv that in the performance of the work for which this permit is Issued, I shall not
employ any person in any manner so as tp c omc sex jeer to the Worked Compensation
Laws of Califo ke Date
Applicant
NOTICE TO APPLICANT: If, alter m ng this Certifiate of Exemption, you should
become subject to the Worker's Com on provisions of the Labor Code, you must
' forthwith comply with such pmvi or this permit shalt be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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
Lender's Address
I certify that 1 have read this application and sate that the above Worrnadon is
' correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above -mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j IiabiBtics,judgments, costs and expenses which may In any way accrue against said City
in consequence of the granting of this permit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE
�D
Re roofs
Signature of ApplieanUContracto Da
HAZARI S MATERIALS DISCLOSURE
_
Type of Roof
Will the applicant or rW= building occupant store or handle hazardous material
as defined by the Cupertino unicipal Code. Chapter 9.12. and the Health and Sarety
Co.. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
[]Yes 1�No
'
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant orfuttum 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.
Disoict7
❑Yes ,P�No -
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534,1 understand that if the building
does no ,II have a tenant, that it is my responsibility to notify she occupant of th
rcq a ich must be a Certificate of Gccu ancy
Signature of Applicant Date
�issuancaof
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All roof coverings to be Class''' or better
Owner or authorized agent ate
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