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CITY OF CUPERTINO
PERMIT+�����«
'
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
19141 MEIGGS LN
TBD — r'0 BE DETERMINED09060172
`TEA'S NAME:
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO.
ARCHITECT/ENGINEER:
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 70W) of Division 3 of the Business and Professions Code. and my license is
RMDL K"CHN ( 141 SQ) ELECT PLMBNG CABNET S , FLOOR—
in full force and effect f
LicenseCl s Lic.
Date � Contractor
, , ,
ANTHON`.r' S CONSTRUCTION PD FOR BUS LIC
ARIZHITECTS DECLARA 1410
nd my plans shall be u cor
LiccrIscd.mfessional
OW NE C[ARATION
1 hereby affirm that 1 am exempt from the Contractor's Liccnse 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
Sq. Ft. Floor Area
Valuation
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
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
3 O O O
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
37537001 .00
❑ Las owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q P
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 docs 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. IL
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.).
❑ 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 Caw 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 exempt under Sec. B & P C for this reason
er Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 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.
and will maintain Workefs Compensation Insurance, as required by Section
f the her Code, for the performan a of the work for which this permit is issued.
i�ave
worker's Comperhsat'on Insula ca ' and Poliry number am:
No.:
ERTIFICATE OF EXEMPTION FROM O ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
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 to become subject to the Workers' Compensation
Laws of Califomia. Datc
Applicant -
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
i
" CONSTRUCTION LENDING AGENCY
+ I hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender'sName
Lender's Address
I certify that 1 have read this application and state that the above information is
' conott I 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.
City Cupertino against
(We) agree to save, indemnify and keep harmless the of
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this �p
" APPLI ERSTAND ?WILL COM WITH ALL NON -POINT
SOU RE TIONS. —,30
Issued b,,: Date
Re -roofs
Si ature licant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of ]hoof
yp
Will the applicant or future building occupant store or handle hazardous material
as defined by the CupertinoInicipal Code. Chapter 9.12, and the Health and Safety
+e, Section 25532(x)?
All roof: shall be inspected prior to any roofing material being installed.
❑Yes No
0Y
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or future building occupant use equipment or devices which
Willemit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia & Safety Code, Sections 25505 34.1 understsnd that if the building
d not c ndy have a tenant Tlis my responsib lily to notify the occupant of the
quirem which must x t prier to issuane cru Icate or pancY.
Signature � of Applicant Date
All roof coverings to be Class or or better
Own r aut orized ager( Da1e