09040053 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Z� } MTX� fi
PERMIT NO.
BUILDING ADDRESS:
23350 SERANO CT VILTA 25 LA CO
PERMIT ISSUE DATE
uNER'S NAME:
S A CONTROL NO.
PION
408) 377-5692
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
c�l.p p LICENSED CONTRACTOR'S DECLARATION Job Description
W r- I hereby affirm that I am licensed under provisions of Chapter 9(commencing
I Z�d with Section 7000)of Division 3 of the Business and Professions Code,and my license is REPLACE EXISTING 200 S Q FT CONCRETE PATIO
n'y in full force and effect
in Z License Class Lic.Con# for
f, Dale
ARCHITECTS DECLARATION
a< I understand my plans shall be used as public records
�yU
L O rn Licensed Pmfcssional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
R m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
a wprior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
7^cCc< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
F G (commencing with Section 7000)of Division 3 of tic Business and Professions Cade)or 2 1 0 0 0
i $ that he is exempt therefrom and Ore basis for the alleged exemption.Any violation of
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(5500). 34255011 . 00
0 1,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
propeny 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.).
Id 1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Prof 'ons Code:)The Contractor's Li.
cense law does not apply to an owner of perry builds improves thereon.and,
who contracts for such projects a c tor( need rsuant to the Contractor's
License Law.
0 I am exempt under Sec. B&PC for ism n
-.,tar S
Date✓ l
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 1 have 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.
0 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 Workees Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section[teed not be completed if the permit is for one hundred dollars($100)
or Icss.)
I certify that in the performance of the k for which this rmit is issued,l shall not
employ any person in any m ncr so come sub' t the Workcrs' pensation
Laws of California.Date
Applicantr(�
NOTICE TO APPLICANT:If,after making th' crtifcare of crept ion,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"4 CONSTRUCTION LENDING AGENCY
E r►�-� I 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.)
W Q Lender's Name
0 Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL 0' cored I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
abovo-mcmtioned property for inspection purposes.
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
04
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U2 in consequence of the granting f thi permit Date
�. APPLICANT U DERSTA S D WILL CO LY WITH ALL N-POJNT Issued b;/: — `�► U�
S URCE RE TIONS.
--� 9
F Re-roofs
rgnature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of:Zoof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
^ode.Section 25532(x)? All roof:,shall be inspected prior to any roofing material being installed.
0 Yes `®910
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 hazardous air contaminants as defined by the Bay Area Air Quality Management all new Inaterials for inspection.
District?
0 Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505. 533 and 25534.1 understand that if the building
docs not current] have a tenant it i my responsibility ,fy the oceu t of the
in ments h roust be met r issuance of a C arc of Occup Signatur:of Applicant Date
N 11d
All roof coverings to be Class" `'or better
Owner or authorized agent Datc