09060058CITY OF CUPERTINO
PEMUT
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
22261 MCCLELLAN RD
TBD — T RE DETERMINED
n9_06.0LSR
OWNER'S NAME.
PERMIT ISSUE DATE
PHO
CONTROL NO.
"T t 't `" W 70 Cxt— 105
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 7000) of Diviri?n 3 of the Business and Professions Code, and my license is
in fall force and
Czj O Z Z
COMPLTN OF EXSTNG OPEN BUILDING PERMIT . FOR NEW
License Gases '" Lie.,
Date Contractor
SINGL FAM HOM 7 ORIG PERMIT # 0 3 0 8 0 010 ,
ARCHITEC`rS DECLARA7ION
1 understand my plans shall be used as public records
DECK/RAILING.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors 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 strtcmre
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pumunt 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 Busioesa and Professions Code) or
$20000
that be is exempt tbetefrom 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 (I500)
35704077 . 0
❑ L as owor the property, or my employees with wags as their sole compensation,
owner
Required Inspections
will do tre wale, and the structure is not intended or offered for sale (Sec 7044, Business
and Professions Coda The Contractors License Law does not apply to an owner of
property who builds or improves thercoo, and who does such worn himself or through his
own employees, provided that such improvements ate not intended or offered for ale. If,
however, the building or Improvement is sold within one year of completioo, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑ L as owner of the property, am exclusively contracting with limited contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's U-
cease Law does not apply to an owner of property who builds or Improves demon, and,
who contracts for such pmjecu with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Due
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
I have and well maintain a Certificate of Consent to self -Insure for Workers 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 Compemation Insuramz as required by Section
37-00 of the Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensationhmm.m.s+^sce canner and Poll umber
Carrie XyF'02 V- Policy
CERTISCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectkm need not be completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that In the performance of the work for which this permit is issued. 1 shall not
employ any person in any manner so as to become subject to the Worland Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after malting this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Libor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONsmucTION LENDING AGENCY
1 hereby affirm that them is ■ construction lending agency for the performance of
ter work for which tMs permit is issued (Sec. 3097, Civ. C.)
-
Lender's Name
Lenders Address
I certify that 1 have read this application and state that the above information is
conecl. 1 agree to comply with all city and county ordinances and sank laws relating to
building construction, and hereby authorise ¢presentative of this city to Aster upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless to City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in eo of the granting of this permdL
APPL ANT UNDERSTAN AND L COMPLY WiTH ALL NON -POINT
S S.
Issued by: Date
Re -roofs
Slknaturc ol'ApplicanUContmctor
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or fuwrc Wilding occupant store or handle hmwdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and tin Health and Safety
Code. Section 25532(s)?
❑ Yes
All roofs shall be inspected prior to any roofing material being installed.
�e
a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupantuse equipment or devices which
emit hvardous air contwninanu as darned by the Bay Ares Air Quality Management
all new materials for inspection.
District? ,,����""
❑ Yes QClvo
1havereadthehvm*msm•r-t requirementsunderChapter6.95oftheCalifor-
nda Health af-ly Cade. Soctior" 25505. 25533 and 25534.1 undesund tut if the building
does not c my have a tenant, tut it is my responsibBi to notify Ilse occupant 01 the
aircm w ra e m 'or once or copincy.
Signature of Applicant Date
All roof coverings to be Class'n' or better
.
Ownerorauthorbrdarc Date