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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10980 SANTA TERESA DR
THE D & M GROUP
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE
SAMt&XY_Nb.CONTROL NO.
(408) 378-4088
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 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 force and effect.
REMDL KTCHN r MINOR STRCTRL INCLDNG
License Class Lin, a
Date Contractor
ELECTRCL , MECHANCL& PLMBING (Z 3 8 SQ)) NO RE—RF & YES
ARCHfrEC 'S DECLARATION
1 understand my plans shall be used is public recants
FOR STRUC TRL
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$70000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
35613001 .00
❑ 1, as owner of the property, or my employees with wages as their sale compensation,
Required Inspections
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 does not apply to an owner of
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.).
L1, as owner of the property, am exclusively contracting with licensed contractors to
ruct the project (Sec. 7044, Business and Professions Code:) The Contractors U.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a comractor(s) licensed pursuant to the Contractor's
License Law,
C]1 am exempt
I hereby affirm under penalty of perjury one of the following declarations:
❑ I ham and will maintain a Certificate 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.
❑ 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPFNSA71ON INSURANCE
(This section need not hecompieted if the permit is foronc hundred dollars (EI00)
or less)
1 moil that in the performance of the work for whicq this permit is issued, 1 shall not
employ any person in any manner so asttfce r�rupihYer the Workers Compensation
Laws of California. Dai;_
Applicant C-44^4 0 u
-
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 permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned 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 accrue against said City
in consequence of the granting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE yULATIO. ^
p�
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defrncd by the Cupertino Municipal Code. Chapter 9-I2, and the Health and Safety
Code, Section 25532(a)?
C] Yes �No
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
g
Will the applicant or future 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.
District? 1111
❑Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand dw if the building
dors
g TT'�}'
A]] roof coverings to be Class's` or better
Owner
or authorized agent Da�—