08090026 CITY OF CUPERTINO
BUILDING DIVISION PERMIT Gfi� R4 +QR I�tIRTXEIN: .
BUILDING ADDRESS: PERMIT NO.
10351 S TANTAU AVE TBD — TO BE DETERMINED _oRp_9_an2F)
NER'S NAME: PERMIT ISSUE DATE
PHONE: S A CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION
V f= 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in Cull Coree and effect HOUSE DEMO 1, 179 '
License Class
Date CControntractor 5/18/09 HABITABLE DWELLING INSPECTION DONE BY PW
t;,p
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
rJs
O H Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
4.� which requires a permit to construct,alter,improve,demolish,or repair any structure
Z 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 Licensc Law(Chapter 9 Sq.Ft.Floor Area Valuation
f—$ (commencing with Section 7100)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for dw alleged exemption.Any violation of $10000
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not more than five hundred dollars($500). 37508017 . 00
p y Type
❑I,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
and Professions Code:The Conuacters License Law docs not apply to an owner of Required Inspections
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,
how ver,the building or improvement is sold within one year of completion,the owner-
)ui r will have the burden of proving that he did not build or improve for purpose of
sa J.
1,as owner of the property,am exclusively contracting with licensed contractors to
construct 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 contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am ex re/ptt under Se B&PSC far this
mason
mer Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 Worker's Compensation Insurance,as required by Section
3710 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 need not be completed if the permit is formic hundred dollars($100)
or Icss.)
I certify rhos in the ormance of the work for which this permit is issued,1 shall not
employ any person in y manner �o c ie�to� orkors!Compensation
Laws of Califo
Applicant
NOTICE To#PP A r making crtificatc of Exemption,you should
become sir ' to the Workces Compensation provisions of thc7M or Code,you must
Oforthwith a ply with such provisions or this permit shall be deemed revoked.
ZZ~ CONSTRUCTION LENDING AGENCY
2
I hereby affirm that there is a construction lending agency for the performance of
Gi the work for which this permit is issued(Sec.3097,Civ.C.)
Wfs.A Lender's Name
0 z Lender's Address
V 0 1 certify that 1 have read this application and stare that the above information is
LL" correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city m enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
UZ A PLIC men oC the granting S this permit. �/�
►" APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date l/
SOURCE NS.
S —/Y—0 Re-roofs
i nat o t/ for Date
/ AZARDOUS MATERIALS DISCLOSURE Type of Rc of
Will the applicant or future building occupant store or handle hazardous material `
'defined by the Cupertino Municipal Code.Chapter 9.12,and tlhc Health and Safety
de,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes a'rro
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants fined by the Bay Area Air Quality Management all new ma'erials for inspection.
District?
C]Yes No
I have rea the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Sof y Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not curve y h a ant,that it is my responsibility to notify the occupant of the
req ' i t rtoissuance ofaCertifhealeofOccupancy. Signature of Applicant Date
All roof coverings to be Class'r `'or better
O ncr ora horn d a ent Date g Y4