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09040065CITY OF CUPERTINO� Y > h ��k BUILDING DIVISION PEMT BUILDING ADDRESS: PERMIT NO. 20189 APPLE TREE LN TBD — TO BE DETERMINED 09040065 OWNER'S NAME: PERMIT ISSUE DATE S CONTROL NO. ARCHn'ECT/ENGINEF.R: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing 70ff0) of D s 3 of dm Business as fcssiont e, and my Ikens is infdlforceandeff Z ADD 546' FAMILY&DINING RM—REMODEL KITCHEN DPS«tion sesta _,' 300',BATH 72' FAMILYRM 296' REPLACE ROOF AR CTS DECLARA oN 1 understand my plans dull be used ss public records FRAMING . INCL STRUCT . NO REROOF . Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for the following reason. (Section 7M I.5. Business and Professions Cole: Any city or county which requires a permit to construct. alter. improve, demodlsh, or mpair any structure prior to its issuance. also requires the applicant for such permit to file a signed stn= •ru Sq. Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professlons Code) or O O 0 that he is exempt therefrom and the basis for the alleged exemption. Any violas am of 1 O O Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more rhea five hundred dollars (S500). 31633096 .00 0 L as owner of the property. or my employees with wages at their sok compensadon, Required Inspections will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business and Professions Code The Contractors License Law does not apply m an owner of property who builds or improves thereon, and who does such work himself orthrough bis own employees, provided that such Improvements are not intended or offered for ale. 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 ale.)_ 0 L as owner of the property. am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Code) The Conrnctnrs 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 Contfactors I i-- Law. 0 I am exempt under Sec. B h P C for this reason Owner Dau WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury am of the following decimations 0 1 hsre tad Will maintain a Car scala of Consent to self -insure for worker's Compeo- ation, as provided for by Section 3700 of the Labor Cook, for the performance of the work for which this permit is in . 0 I 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 CampyanWi Inst carrier and Policy number amIQLAe'u: c Carrier. Vi I>y /�f Policy No.; :2 T 71 ~ CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (I'hks season need not be completed U the permit is forone hundred dollar (510(l) or lest) 1 certify that In the performance of the work for which this permit is Issued. 1 shall not employ any person In any manner so as to becoma subject to the Woriara' Compensation Laws of California. Dam AppOe'^' NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this peamit shall be damed tevolmd 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 (Ser:. 3097, Civ. C.) Lenders Namc Lenders Address I artily that I have read this application and state that the above information Is correct. I agree to comply with all city and county ordinances and sue laws relating to building construction, and hereby authorize mpresentatives of this city to enter upon the above-mentioned property for Inspection purposes. 1) (We) agm e to ave, Indemnify and keep harmless the City of Cupertino against liabilities, judgments. costs and expenses which may in any way accrue: against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AtQ WILL COMPLY WITH ALL NON -POINT Issued by: Date✓2 �S soURC ip �(� _ (�'� Re -roofs Ji Signature of Appfl t/Contractor Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the 4plkt or future building o cupam store or handle haardons material as deAned by the Cupertino Musticipal Code. Chapter 9.12, and tin Health and Safety CDdc,Section 25532(a)7All _l ❑Yes �No 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 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? Cl Yes )1Qo I have mad the hazardous materials m 6.95 of the Califor- materials requir cw under Uupe nia 1th &Safety Code, Sections 25505, 25533 .1 undasard dss if the building Health docs not currently have a tenant, tha it is my adbi to notify de Decupa,et of the regDirementa i ,camofam*mwy. Signature of Applicant Date zg All roof coverings to be Class "/�" or better Dam ' Owner or aothcrizad nt u. CITY OF CUPERTINO BUILDING PERMIT -� L_u BUILDING ADDRESS: 20189 APPLE TREE LN CONTRACTOR: JOHN MCCUNE PERMIT NO: 09040065 CONSTRUCTION 16 - OWNER'S NAME: SAN JOSE, CA 95119 PHONE NO: (408) 227-2700 ❑ LICENSED CONTRACTOR'S DECLARATION r r r BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic. # r r MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: ADD 546' FAMILY&DINING RM -REMODEL KITCHEN 300',BATH 72' FAMILYRM 296REPLACE ROOF (commencing with Section 7000) of Division 3 of the Business & Professions FRAMING.INCL STRUCT. NO REROOF. Code and that my license is in full force and effect. 5/20/2010- REVISION H 2 REVISE HALL CEILING I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the Sq. Ft Floor Area: Valuation: $100000 performance of the work for which this permit is issued. 1 have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 31633096.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN'180 DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply Issued by: Date: with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. RE -ROOFS: Signature Date All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, 1 agree to remove all new materials for inspection. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 or offered for sale (Sec.7044, Business & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec.7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(x) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Cade, Chapter 9.12 and I have and will maintain Worker's Compensation Insurance, as provided for by the Health & Safety Code, Sections 25505, 25533, and 25534. Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Owner or authorized agent: Date: I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's Compensation laws of California. If, after making this certificate of exemption, I CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, I must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that I have read this application and state that the above information is correct. I agree to comply with all city and county ordinances and state laws relating 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 liabilities, judgments, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records. granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. Signature Date