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CITE' OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10351 S TANTAU AVE
TBD - TO BE DE
OWNER'S NAME:
PERMIT ISSUE DATE
A 0. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING 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 force and effccL
2 STORY SFDWL 3,628' ATTACHED GARAGE 5 5:2 ' -
License Class _ Lic. #
Date Contractor
SANITARY
ARCHrMCPS DECLARATION
I understand my plans shall be used as public records
IS SUNNYVALE'S JURISDICTION -NO INSPECT REQD-DEMO
REQD
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
that he is licensed pursuant to the provisions of the Contractor's 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 of
$800000
APN Number
Occupancy
p y Type
Section 7031.5 by any applicant for a permit subjcros the applicant to a civil penalty of
not more than five hundred dollars ($500).
37508017.00
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such improvements are not intended or offered for We. 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. .
C]- , as owner of the property, am exclusively contracting with licensed contractors to
canstroct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractmr(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exemptde ccB & P C for this reason
Owne Datc
Y W MrS MRPENSATMKDFCLARATTON
If1hereby affirm under penalty of perjury one of the following declarations:
❑ i and will maintain a Certificate of Consent to self -insure for Workers Compen-
satio , 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
'
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notbe completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performa cc of the work for which this permit is issued, I shall not
employ any person in any m ncr as tolrccomc su ' t to thW kers' Compensation
'—
Laws of California. Da
Applicant
NOTICE TO APP : It. after making is cgfc o'f iemplion, you should
become subject to l c orker's Compensation provisions of the Labor Code, you must
forthwith comply city such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby AM that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
'
Lenders Name
Lenders Address
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize representatives mf 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 consequent of the granting of this permit.
APPLICAN,r UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE U 10 S.
Re -roofs
Type of Roof
�- — _ ()
SiJnqVrc oVpoicbkcomror Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eccupantstore or handle hazardous material
defined by the Cupertino Munic' al Code, Chapter 9.12, and the Health and Safety
.de.Section 25532(a)?
�[]
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
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
crit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes Lyvu
1.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safetytode, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently that it is my responsibility to notify the Occupant n( the
bmenant.
re urremc w o o issuance of a Certificate of Occupancy- y �
p�az'n`d�
Signature of Applicant Date
LTJ ` _�
,7
All roof coverings to be Class'n" or better
O Wr rrhn ' .ed een Date J