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CITY OF CUPERTINO
BUILDING DIVISION PERIVIIT�11z
BUILDING ADDRESS:
PERMIT NO.
19500 PRUNERID E AVE
DRAEGER
OWNER'S NAME:
JN
PERMIT REM DATE
PHONE:
e e CONTROL NO.
(408)536-0420
ARCHrtT:CT/ENGINEFR:
BUmmiNic PERMITINF-0
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Jb Description
o
I hcmby affirm that I am licemed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Pmfcsskw Code, and my license is
in full force and effect.-71
SHORE UP DECKS & STAIRS # 3 0 6 & 307
a
LicenseCl Lic_
Date CO..
HIIECFS DECLARAMON
I understand my plan shall be used as public records s
I rC•-
Licenacd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that i am exempt from elan Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to COM17iruct, aher. improve, demolish, or repair any structure
prior to is issuance, also requires ft applhant for such permit to file a signed sah`Ncni
dal he is licensed pursuant to the provisions of the Contractor's Llcc nse 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 amption. Any vloladon of
APN Number
Occupancy
Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SSO(1).
316 0 6 0 3 7 . BLDG 5
❑ L as owner of the property, or my employees with wages as deer sole ernnpensation,
Required Inspections
will do the work. and the structure is not intended or offered for sale (Sec. 70", Business
and Professions Code The Contractors Lkense Law does not apply to an owner of
property who builds or improves thereon, and who thou such work hhorelf or through his
own employe, provided that such impmvcmers are not intended oroaaed 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.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec, 7044, Business and Professions Code-) The Ceotractoes Li-
cense Law does wx apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a eonractor(s) praised pursuant to the Contractors
L.icems raw.
❑ I am exempt under Sec , B h P C for this rrasom
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby afire under penalty of perjury ono of the following declarations:
❑ i ham and will maintain a CmlBcate of Consent to self -insure for Weukeez Compcn-
scion, 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 Worker's Compensation Insurance, as required by Section
_
3700 of the Labor Cook, for the performance Of the work for which this permit is issued.
My Worker's iO�mperrFtiom ImEran= Carrier and Policy number are:
II
Cartier Policy No.:
CERTiFI OF EKEMPITON FRO ORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit Is issued, I shall not
employ any person in any manner so as to become subject to the Woimts' Compensation
Laws of Califorda. Dare
AppBtant
NOTICE TO APPLICANT` If, after making this Certificate of Exemption, you should
become subject to Iha Workers Compcosauion provisions of the L beer 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 convxucdon lending agency for the performarrte of
the work for which this permit is issued (Scc- 3097, Civ. C.)
Lender's Name
Lentlm•s Address
I certify that 1 have Ind titia application and note that site above InfeamaaOn is
cormcL 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
abovo-mcntioned 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 acc= against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITT-1 ALL NON -POINT
Issued by: Date
S011RICE G S.
ICRe
-roofs
Type of Roof
Si m of kcanVContractor UDue
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ommpunL store orhandk hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, SectionYes 25532(a)?
All roofs shall be inspected prior to an roofing material being installed.
P P� Y g g
[-I Yes >�Nm
future
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or 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.
Dsrkt7
❑ Yes [ Qo
I have read the hazardous materials requiremew under Chapicr &95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. i undcrrand that If the building
does not currently have am- thu it it my responsibility to noury ate occupant of the
which met prior to' of a Ie of Ompancy
rl`°i�"
Signature of Applicant Date
f
All roof coverings to be Class','jt " or better
U batc
r or col agent