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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
��1'TAC1 IUYAkI�N
BUILDING ADDRESS:
PERMIT NO.
10319 MC KLINTOEX LN
COLD
OWNER'S NAME:
PERMIT L95UF DATE
�' 408)374-7292
ARCH1 ECr/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
-
infullfomeandeffeet. (,p 2 2
REMOVE ONE 4 TON HEATING/AC SYSTEM. INSTALL 2
LICEnsc Class Lrc. # �%�
'
Date2;4 C nttzcwr �Icj f/A
UNITS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
(6 TONS)-REPL(E)DOWNSTAIRS UNIT,ADDING NEW UNIT
IN -
Licensed Professional
OWNER -BUILDER DECLARATION
ATTIC
I hereby atfrm that I am ucmpt from the Contractor's License Law for the
following mason. (Section 703 L5, 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 Contractors 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
S24386
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
34215043.00
❑ L as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec.7044. Business
and Professions Codc: The Contractor's License Law does not apply to an owner of
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 have the burden of proving that he did not build or improve for purpose of
sale.).
ci I. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contnctor(s) licensed pursuant to the Contractor's
,
License Law.
1 am exempt under Sec , B & P C for this reason
-
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 or the Labor Code, for the performance of the
wort 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 Workers Compensation Insurance artier and Policy number am:
WORKERS'
COMPENSATION INSURANCE
(tins section need not be completed if de permit is forone hundred dollars (SI00)
or less)
I ccrdly that in the performance of the work for which this permit is issued, I sha11 not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California Dale
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a contst uctinn lending agency for the performance of
the work for which tbis permit is issued (Sec. 3097, Civ. C.)
Lenders Namc
-,
Lender's Address
1 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, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APP ICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date �- LT
. O�
Re -roofs
—
S' rc of A /Contractor Date
plican
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the apptiantor future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Co., Section 25532(a)?
yes 1! Na
All roofs shall be inspected prior to any roofing material being installed.
C:
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 Nu
1 have mad the hazardous materials requirements under Chapter 6.95of the Califor-
nia lien)th & Safety Code, Sections 25505.25533 and 25534. I understand thetif the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
ts which must be met prior issuance nia Cenificam of Occupancy.
Signature Of Applicant Date