08100201CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
21885 MCCLELLAN RD
TBD — TO BE DETERMINED
:
S Y CONTROL NO.
ARCHITEC'r"GiNEER
BUILDING PERMIT INFO
DEMO EXTNG 60YR OLD
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LICENSED CONTRACTOR'S DECLARATION
HSE (13 0 0 SQ) INORDER Jb&DeiiWon
I hereby affirm last I am licensed under provisions of Chapter 9 (commencing
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with Section 70W) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
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License Class Lie. 0
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Date Contractor
' ARCHITECTS DECLARATION
I understand my plans shall he used as public records
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Licensed Professional
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OWNER -BUILDER DECLARATION
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1 hereby affirm that i am exempt from the Contractor's License Law for the
Business and Professions Code: Any city or count
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prior to its issuame. also requires the applicant for such permit to file a signed statement
that he is licensed to the of the Contractor's License Law (Chaps r 9
Sq. Ft. Floor Area
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pursuant provisions
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(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he Is exempt themfrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Oeeu ane e
P Y TYP
not more than five hundred dollars (S30"
❑ I, as owner of dic property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and the structure la not intended or offered for sale (Sec.7044, Business
and Professions Cade: The Contractor's Umax 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
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 haw the burden of proving that he did not build or improve for purpose of
sales).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The CDnu=orS Li.
tense Law does not apply to an owner of propeny who builds or improves thereon, and,
who contracts for such projects with a comractor(s) licensed pursuant to the Contractors
License Law.
❑
i hereby affirm under penalty of duty one of the following declaration
❑ I have and will maintain a CertlG of Consent to self -insure for Workers Compen-
sation, 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 wort for which this permit is Issued
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My Workers Compensation Insurance artier and Policy number am:
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Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSA31ON INSURANCE
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(this section need not be completed if the permit is for one hundred doliara ($100)
or less.)
I certify that In the performance of the work for which this permit is issued, I shall not
employ any person in an r so as to become jCct to the Workers Compensation
Laws of Califarnin
Applicant
NOTICE TO
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forthwith comply with such provisions or this l shall be deemed revoked.
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CONSTRUCTION LENDING AGENCY
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I hereby affirm that them is s construction lending agency for the performance of
the for issued C.)
wort which this permit is (Sm 3097, Civ.
L.cndces Name
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Lenders Address
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1 certify that I have read this application and state that the above information is
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correct. I agree to comply with all city and county ordinances and state laws relating to
construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
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(We) agree to save, indemnify and keep harmless the City of Cupertino sgainst
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liabilides, Judgments, costs and expenses which may In any way accrue agaiast said City
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in con ee of the granting of this permit
AP IC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued : Date
ate
HAZARDouS ATERIALSDISCLOSURE
Will the applicant or future ding occupant atom or handle hazardous material
as defined by the Cupertino Mu opal Code. Chapter 9.1Z and the Health and Safety
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Code, 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yea
[] Yes ❑ 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 as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cali for -
Out Halth ctycodc,Sections 25505,25533and 25534.1understand thuUthe building
does n re y have a tenant to notify the occupant of the
re nts