09040135CITY OF CUPERTLNO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19639 MERRITT DR
FERMI NO.
OWNER'S NAME:
ARCHrrF=/ENCI+ NEE*
I heeby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700t1) of Division 3 of the Business and Professions Code, and my license Is
n full force and effect
License eras Lic. R
Dale ContracWr
CHITECTS D
I understand my plans shall be used as public records
Licensed Professi nal
OWNER -BUILDER DECLARATION
I hcmby affirm that 1 am exempt from the Contractor's License law for the
following mason. (Section 703 ". 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
(commencing with Section 7000) of Division 3 of the Business and Profrnions Code) nr
that he is exempt therefrom 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
not more than five hundred dollars (S500).
❑ L as owner of the property, or my empiayces with wages as their sok compensation,
will do the work, and the structure Is not intended or offered for sale (Sec. 70". Business
and Professions Code The Conuactots L.kensc Law does riot apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employers, provided that such improvements are not intended or offered for sale If.
however. the buMng 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
sales).
❑ L as owner of the property, am exclusively contracting with Ilmaaed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors L�
come Law doe riot apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a tonuactor(s) licensed pursuant to the Conuscmes
License Lew.
❑ I am exempt under Sec B & P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby &Mrm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Workees 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, u required by Section
3700 of the Labor Codo, for the perfo a of the wort for which thus permit is Issued.
My
section need Trot be compicted if the permit is for one hundred dollars ($100)
or Ioss.)
1 certify that in the performance of the work for which this permit is issued. I sun not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the labor Code, you must
fortbwith comply with such provisions or this permit shall be domed revmkcd.
CONSTRUCnON LENDING AGENCY
1 hereby affirm that there. is a construction lending agency for the performance of
de work for which this permit is issued (Sec. 3097, Civ. C.)
Landes Name
Lenders Address
1 certify that 1 have read this application and sue that the above information is
correct. I agree to comply with all city and county ordinances and a= laws relating to
building construction, and hereby mthorim representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to aave, indemnify and keep harmless the City of Cupertino against
liabilities. Judgments, touts and ex which may in any way accrue against said City
In consegtrerrce of mho rag this permit
APPUCANT U S AND WILL COMPLY WITH Aft. NON -POINT
SOURCE REG ON
2 /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardons material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑ Yes R�No
Will the applicant or future building occupant use equipment or devices which
emit ha7andous air contaminants as defined by the Bay Area Air Quality Management
Dies na7 \/
(]Yes 1Cl No
1 have read the hazardousmaterialsre quiremcnts under Chapter 6,95 oldie Califor-
nia Health & Safety Code. 25M5, 25533 and Z5534.1 understand the if the building
does not currently hive a t, dot it is my responsibility to notify the occupant of de
mquimmems m met prior to issuance of a Certificate of Occupryncy.
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
ADD 27SQ TO KITCHN& REMDL KTCHN 152SQ;S,TRUCTRL,N0
Issued by:
Re -roofs
Type of Roof
DatesI-
All 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
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class". ' or better
l7lb�