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CITY OF CUPERTINO
PERMIT
a a
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
19500 PRUNERIDGE AVE BLDG 8
DRAEGER CONSTRUCTION
OWNER'S NAME:
PERM" ISSUE DATE
PHONE;
O. CONTROL NO.
(408)536-0420
ARCHITEC (ENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full to= andeffe
SHORE UP DECK &STAIRS #302
Licevx a
Date 10Contractor
CHI7ECT'S DECIARJM6N
I understand my plans shall be used as public records
Licensed Professional
OWNER-HURDER DECLARATION
I hereby affirm that lam exempt from the Contractors Lice= Law for the
following reason. (Section 7M 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolW- 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 Conlin ors License Law (Chapter9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
12 18
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy T
Pant Y Type
Section 7031.5 by any, applicant for a permit subjects the applicant to a civil penalty of
not more than fire hundred dollars cs5oo)
3 16 0 6 0 3 7 . BLDG 8
C7 L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structwe to not intended or offered for sale (Sec- 7044, Business
and Professions Code: The Contractor's I seen Law does not apply to an owner of
property who builds or improves I and who does such work h(mself or through his
own employee&, provided that such improvements ere not intended or offered for silt. 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 imprm for purpose of
sale.).
❑ L as owner of the property, am exclusively contracting with licensed contractor: to
construct the project (Sec 7044, Business and Professions Code:) 7be Contractor's Li-
cense Law does not apply to an owner of property who buBds or improves thereon, and,
who contacts for such projects with A contractor(s) licensed pursuant to the Contractor's
Llcenae Law.
❑ I am exempt under Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certillcm of Consent to self -Insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code for the performance of the
work for which this permit is Issued
C] I have sod 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 W Coanpen Itlon I usvnce carrier sailPolicy number ere: `
Cartier. I Policy No : ) 1 � `
L
CERTTF7 F EXFMFnON FROM WORKERS
COMPENSATION INSURANCE
(This section reed not be completed tribe permit Is for one hurdled dollars (SI00)
or less.)
I certify that in the performance of the work for which this permit is issued, I shill not
employ any person in any maanerso as to became subject to thc Worked Compensation
Lima of California. Dale
Applicant
NOTICE TO APPLICANT`. If, alter making Nis Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code. you must
ronhwiN comply with such provisions or this permit shall be drrmed revoked.
CONSTRUCIION LENDING AGENCY
I hereby alarm tlw there is a construction lending agency for the performance of
the wort for which this permit is issued (Se&. 3097, Civ. C.)
L.orrdcr's Name
lendee3 Address
I certify that I have read this application and sure that the above information Is
.
comet. 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 roux upon the
above -mentioned pmperty 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 accrue against said City
in consequence of the granting of this permit
AP C UPMUWANDS AND COMPLY WITH ALL NON -POI
Issued by: Date
U NS.
ZILTRe
-roofs
Type of Roof
S um IicarrUContractor ale
HAZARDOUS ATERIALS DISCLOSURE
W111 the applicant or future building occupant gore or handle haardous material
as defined by the Cupertino Municipal Code- Chapter 9.12, and the Health and Safety
Code. Oyes 25532(a)7
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
Will the applicant or fafine buildin own
pp a pant tense equipment or devices which
Omit hazardous air contaminants as defined by the Bay Area car Quality Management
all new materials for inspection.
DisaicO
❑ Yes 1No
/`
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, Z533 and 25534. I undarsta id this. if the building
does not currently errant that it is my responsibility to notify the occupant of the
w h bemetpi fa ofOccup—yr
Signature of Applicant Date
All roof coverings to be Class 'A" or better
a r orvrd agent atc