09030221CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
19500 PRUNERIDGE AVE BLDG 3
DRAEGER CONSTRUCTION
OWNER'S NAME.
PERMIT ISSUE DATE
PHONE_
CONTROL NO.
(408)536-0420
ARCHITECTlENGINEER-
BUILDING PERMrr rNFo
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
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Job Description
I hereby LTirm Thar I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professsons Code, and my license is
InfdlrorceVACff=LQ 7
SHORE UP DECKS & STAIRS #305 &304
Lkenac el Lie.
Date Contractor
ARCfii 1ECTS D T10
1 understand my plwns shall be usod as pub c records
d
Licensed Professional
OWNER -BUILDER DECLARATION I
I hereby ai6rm that 1 Am exempt from the Contractor's l icrnsc Law for the
following reason. (Section 7031-5, Business and Professions Code: Any city or county
Which requires a permit Lo cortslrucL alter, imprOK, demolish, er repair any structure
prior to its issuance, silo requires the applicant for such permit to file a signed suumneni
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions or am Contractors i.icense Law (Chapter 9
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
2 4 3 6
Ilea he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00)
31606037.BLDG3
compensation,
❑ Las owner of the property. to , y employeesyemployeeswith wages asale compensation,
Required Inspections
will do the work. and the structure is not intended or offered for sale (Sec 7044, Busi trss
and Professions Coat" The Contractors I is = Law does am aapply to an owner of
property who builds or Improves Hereon, and who does such work himself or through his
own employee, provided that such improvements are not intended or offered for ale- If.
however. the building or improvement is said within one year of completion. the owner -
builder will bare the burden of proving that he did not build or improve for purpose of
sale.)_
❑ I. as owner of the property. am exclusively contrac"s with liatued contractors to
construct the project (Sec 71)", Business and Professioru Code:) The Contraanrs Li -
cease Law does not apply to an owner of property who bonds Or Improves thereon, and ,
who contracts for such projects with a eontractar(s) licensed pursuant to that Contractors
License taw.
❑ I am exempt under Sec . B k P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm miler penally of perjury one of the following declarations
❑ 1 ham and win maintain a Certificate of Consent to self -insure for Workers Compen-
sadon, as provided for by Section 3700 of the Labor Code, for the pedormarKx of the
work for which this permit is issued
❑ I have and wnL maintain Wortrrs Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is W seed
'
My Wert�a�t m carrier and PalieIL %b�er�aQm^:
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11
Cartier Policy Na: / `^ti' ��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or lcsL)
I certify that in the performance of die wort for which this permit is ISNmd. I shall not
employ any person In any mauner so as Io become subject to the Workers' Compenvtion
Laws Of CalifOmiL Date
Applicant
NOTICE TO APPLICANT: if. after making this Certificate of Exemption, you should
became subject to the Wortcrs Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be damned ievoked
CONSTRUCTION LENDING AGENCY
I hemby affirm that dicre is a consuucdem lending agency for the performance of
the wort for which this permit is issued (Sec- 3097, Civ, C)
Lenders Name
,
].enders Address
I certify IhaL I have read this appliearion and awe thu the above information u
conecL 1 agree to comply with all City and county ordinances and state laws misting to
building construction, and hereby authorize represcnwives of this city to enter upon the
above -mentioned property for inspection purposes.
(%) agree to sam indemnify sad keep harmless the CILy of Cupertino against
liabilities, judgments, cosu and expenses which may in army way scenic against said City
in consequeriee of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH All. NON -POINT
C
Issued by: Date
ONS ^
Re -roofs
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Type of Roof
A tant/ContractDam
HAZARDOUS MATERIALS DISCLOSURE
Will the appilant or future building occupant store or handle hrcwdous material
as defined by the Cupertino Municipal Code. chapter 9. It and the Health and Safety
2ss32(.r
Code, Secti0e
All roofs shall be inspected prior to any roofing material being installed.
Yes @'No
If a roof is installed without first obtaining an inspection, I agree to remove
WIII Ilse applicant or futons building occupant use equipment or devices which
emit hazardous air contaminaru as defined by the Bay Area Air Quality Management
all new materials for inspection.
DLsirict7
❑ Yes FO
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Halth $ Safety Code, Sections 25505. 25533 and 25534.1 understand due If the building
does not 9FTVWy dear i " responsibility to notify the occupant of the
be met pri to iSau of C4111 10 of Occu
S
Signature of Applicant Date
All roof coverings to be Class'%" or better
wIhOIU.Cd agent ato