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BUILDING DIVISION PEPJMT
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PERMIT NO.
BUILDING ADDRESS:
10170 PENINSULA AVE
TBD — T
OWNER'S NAME:
PERMIT ISSUE DATE
PHOiZE
tttt—fCONTROL NO.
ARCHiTECTIENGiNEER
BURRING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
1 herby alBnn dust 1 am licensed under provisions of Chapter 9 (commencing
with Section 700M of Division 3 of the Business and Profcsaions Code, and my licenm is
in full fore and effect
NEW SFDWL 2 STORY 2,445' GARAGE 430'
License Clans Lk. r
Date Contractor
ARCHITECTS DECLARATION
1 undersand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alcor, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that be is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(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
$400000
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty or
dollars
APN Number
Occupancy
enc) P y TYPe
not mom than five hundred (5500
3 2 6 2 2 0 3 7 . 0 0
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is riot 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 bonds or improve 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. .
L as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Set 7044, Business and Professions Cade:) TTe Contractor's Li-
.
cense taw docs not apply to an owner of property who builds or Improves thereon, and ,
whocontracls for such projects with a cone a ;wr(z) licensed pursuant to the Contractor's
Lkenae Law.
❑ 1 am elm nder Set B & P C for this naso
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Owner L •
WOR 'S 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-
Won, 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 Workers Compensation lawrance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
My Walters Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OP EXEMPTfON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred doom (5100)
or Iso.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any maqker so as to become subs so ieWorYen�Canpanaatlon
Laws of Calir^
APPB�
NOTICE' 0 APP : If, alter making this Certificate of Fsemphon, you should
become subject to the Workera Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peanit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 hereby affirm that dere is a concoction lending agency for the performance of
the work for which this permit is issued (Set 3097. Civ. C)
Lenders Name
Iend ers Address
I certify that I have read this application and stare thal the above Information is
correct I agree to comply with all city and county ordinances and state taws relating to
budding construction, and hereby authoris representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep han tless the City of Cupertino against
liabilities, judgments. cuts and expenses which may in any way accrue againat said City
in consequence of the granting a(this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S URGE REGULATIONS. \ �
/
Re -roofs
�
Signature of Applicant/Contractor Dale—
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof 1 �"
Will the applicant or future building eeupant stone or handle hazardous material
as dented by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
'
Cove. Section 25532(a)TAll
roofs shall be inspected to any roofing material being 'nstalled
[3 Yes
Jut=building
prior
a roof is installed without first obtaining an inspection; Iagree to remove
Will the applicant occupant use equipment or devices whichIf
Will the applicant building occupant use equipment or devices which
emit hazardous air conaminana u cleared by to Bay Area Air Quality Management
all new materials for inspection.
DivWctT
❑ Ya o
:2
1 have read the requiremerns under Chapter 6.95 of the Califor-
nia Hcalth & Safety Code Sos Liam 25303.23533 W25534. I understand thatif the building
does not asrrenty have a rw L that it is my m pons(bility to notify the occupant of the
r irerrucnts which4smst be mel prior to issuance of a Cctificate of
Signature of Applicant Date
All roof coverings to be Class''/'' or better
Owner Dae
or authorized agent