09030220 CITY OF CUPERTINOr p
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMrr NO.
19500 PRUNERIDGE AVE RI-M, 1 DRAEGER
VNER'S NAME: PERMrr ISSUE DATE
PHOAFTINE APT GGWRYIN�ETIES APF
A CONTROL NO.
408) 535-0420
ARCHI7ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code.and my license is
in full force andeffe SHORE U? DECKS & STAIRS #309, 305&301
Z License Claz p5tbfLic.if /,
E
-,Z Date Contractor (lV_r (t,r�
A CHITECTSDECLA O /
Cd< 1 understand my plans shall be used as public records
DyU
L oin Licensed Professional
r, OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
st
'00
Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
Z yy prior to its issuance,also requires the applicant for such permit to file a signed statement
G that he is licensed pursuant to the pmvisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y R E that he is exempt therefrom and the basis for the alleged exemption.Any violation of 83654
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
316 0 6 0 3 7 .B LDG 1
❑I,as owner of the property,or my employees with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044.Business
and Professions Code:The Contractor's License Law docs not apply to an owner or Required Inspections
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.).
[11.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's U.
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 Contractor's
License Law.
)I am exempt under Sec B&P C for this mason
,vner 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-insum for Worker's Compen-
sation,az 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 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 Workcesy m on logca;,,,dP*1,:.,,,mber areCartier. , �asliryCERTIFICAIXErION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I ccniCv that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so az 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
[~i C4 I hereby affirm that there is a construction lending agency for the performance of
a 2 the work for which this permit is issued(Sec.3097.Civ.C.)
WQ Lender's Name
0 Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
V.r-r correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
�y (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit
Date
APPLICA UND NDS AND jW!��COMPLY WITH ALL NON-POINT Issued by: .J CT
S0
u TI
�- S Re-roofs
SiWX of plicae ontractor a
HAZARDOUS MATERIALS DISCLOSURE Type of R)of
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
,de,Section 25532(a)? All roofs:hall be inspected prior to any roofing material being installed.
❑Yes rture
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or f building occupant use equipment or devices which
emit hazardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
District?
[3 Yes NO
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not clirrendybave a tenant,that it is my responsibility to notify the occupant of the
rem is wh1tAusL be met prior 0orssatipce era Certificate of Oc cy.�G Signature A Applicant Date
o r nthnrid agent a� All roof coverings to be Class''"or better