09040148FYOF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
21.421 MI
OWNER'S NAME:
ARCHITECT/ENGINEER:
u O p LICENSED CONTRACTOR'S DECLARATION
U p 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z U with Section 7000) of Division 3 offt Business and Professions Code, and my license is
< a in full farce and effect.
j 2 Z License Cl Lie. tI 7 !
+Fa Date_ Contractor
ARCHnECrs DELLA ON
' U I understand my plans shall 6c used as publii4econis
a
4 o y Licensed Professional
n y OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
00 fallowing reason. (Section 703 1.5, Business and Professions Cade: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
y Z y prior to its issuance, also requires the applicant for such permit to fele a signed statement
fso
that he is licensed pursuant to the provisions of the Cantracior's License law (Chapter 9
nh � (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he is, exempt therefrom and the basis for the alleged exemption. Any violation of
Section 10313 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars (5500).
0 ), as tinter of die 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
and Professions Code: The Contractors License Law does Ila! 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.).
0 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a commctor(s) licensed pursuant to the Contractors
License Law.
0 1 am exempt under Sec B & P C for this reason
Owner _ Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the perfarn6ce of the
work for which this permit is issued.
0 ) have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My
FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars ($100)
or less)
I certify that in the performance of the work for which this permit is issued, ( shall 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 Worker's Compensation provisions of the Labor Code, you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
r y
[� "+ I hereby affirm that there is a construction lending agency for the performance of
iY+ > the work for which this permit is issued (See. 3097, Civ. C.)
aQ Lender:: Name
.z Landers Address
U Q II certify that I have read this application and state that the above information is
U. "" correct. I agree to comply with all city and county ordinances and state laws relating to
0V building: construction, and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
to liabilitie:s,judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
r . APPLICANT UNDERSTANDS I D WILL PLY WITH ALL NON -POINT
SOURC.
Dale
HAZARDOUS MATERI DISCLOSURE
1 the applicant or future building upant store or handle hat ou i material
as t d by the Cupertino Municipal Co , Chapter 9.12, and the Health and Safety
Co , Scction 25532(a)?
C Yes (KNo
Will the applicant or !future building occupant use equipment or devices which
cmil hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
0 Yes
I have read the hazardous/ materials requirements under Chapter 6.95 critic Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. )understand thatif the building
does not currently have aynrtant. that it is yyyy responsibility to notify the occupant of the
reauirornuts Ccitificacc of Occuoancv. /
408)761-11
Job Description
RMDL KTCH(150)& BTH(300)
Ft. Floor Area
32641106.00
Required Inspections
Issued by:
Valuation
Type
Date (�.� - Z Q
Re -roofs C./
Type of Roof
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 'A"' or better
PERMIT NO.
PERMIT ISSUE DATE
WAi
809
CONTROL NO.
BUILDING PERMrr INFO
BLDG
ELECT
PLUMB MECH
Job Description
RMDL KTCH(150)& BTH(300)
Ft. Floor Area
32641106.00
Required Inspections
Issued by:
Valuation
Type
Date (�.� - Z Q
Re -roofs C./
Type of Roof
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 'A"' or better
Assessor's Parcel Number.._ -� 2 -
Name of owner.
Project address.
Contact person,
Net square footage of lot.
Square footage: First floor: '
Second floor:
Garage:
TOTAL:
Phone,
Pax.
Existing P
Loposcd
Are there at least two 10 foot by 20 foot clear spaces inside the garage'? Y N
Is Privacy Protection Planting required for the project? Y
l3uild it Green Total Points
On what floor(s) is work being done?
Brief description of work.
Code editions: 2007 CBC N)2007 CFC- N)2007 CMC ((YD N)
2007 CPC 9Y.
N)
Effective 1/1/08
Man Review }'recess Work Book Page -8-Rcvised 8/0.5/08
;96 -ed 198ME906 V1E:0T 60OZ19Z U,ffV
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