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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
19500 PRUNERIDGE AVE BLDG 7
DRAEGER CONSTRUCTION
OWNER'S NAME:
PERMIT L$UE DATE
PHONE:
O. CONTROL NO.
(408)536-0420
ARCHITECT/ENCiNE 31-
BUILDING PERMITiNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapw 9 (commencing
with Section 7000) of Division 3 of the Business and Prof,Code, my license is
in full force artdeff 4 �/ eft
SHORE UP DECKS & STAIR #304
Lkencc Clara Ix. It
.
Date Contractor
AR HrrWrS DEC TTON e
I understand my plans shall be used as po records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors IJccnse Lary for the
following mason. (Section 7031.5, Business and Professions Code: Any oily or tvumy
which require a permit to conaWct, alter, improve- demolish, or repair any structure
prior to its issuanm also requires the applicant for such permit a file a signed su anent
that he is licensed pursuant to the provisions of the Contractors License 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 exemption. Any violation or
2 4 3 6
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
P Y yea
rim more than fro hundred dollvs (S500).
316 0 6 0 3 7 . BLDG?
❑ L as owner Of the property, er my employees with wage, as their sole compensation,
Required Inspections
will do the work, and the sttuctum is rat intended or ofkred for sale (See. 7044, Business
and Professlora Code: The contractors License Law does not apply to an earner of
property who builds or improves thereon, and who does such wort himself or through his
owo employees, provided that such improvements are not Nmnded or offered for sale (f.
however. the building or Improvement is sold within one year or 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 pmjea (See. 7044, Business and Professions Code:) The Contractors IJ-
cause Law does not apply to an Owner of property who build& or improves thereon, and.
who contacts for such project& with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec B & P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following 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, far the performance or the
work for which this permit is issued.
❑ 1 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 Worker's rope Irt& w= carrier and Policy number am:
C-P} I
!"
Carrier. PolicyNO
CERTIFICAIIE O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronne hundred dollars ($I00)
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 In become subject to the Workers' Compensation
Laws of California. Data
Applicant
NOTICE To APPLICANT: if, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this peanit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I heeby affirm that them Is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ, C.)
Lenders Nuoc
Lender's Address
[ certify that I have read this application and sore that the show Information is
correct l 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
above -mentioned property for Inspection purposes
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, touts and expenses which may N any way accrue against said City
in consequence of the gran ' 8 of this permit
APPLICANT NDE IDS:AND W L COMPLY WITH ALL NON -POINT
Issued b Date S
y
�A p�1+'�
//
Re -roofs
Type of Roof
(
SiggalItz O icant/Contaetof q Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hrardow material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)T
❑ Yes
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 future building occupant Use equipment or devices which
emit hvardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Diauict7
Q its (lee
1 haw read the hmrdo ,s materialsrequirementsuodcr Chapwr6.95 of the Califor-
riia Health & Safcty C 'ors 25505, 25533 and 25534. I understand tut if the building
my ant that It rsibility m notify the occupant of
-
wh be met prior ofa "caaofOc �//4;
�9...nzcd
Signature of Applicant Date
All roof coverings to be Class'/.'' or better
Dane
scent