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CITY OF CUPERTINO--
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10510 OAKVILLE AVE
CRAFTSMENS GUI IN
OWNER'S NAME:
PERMIT ISSUE DATE
AWAWNb. CONTROL NO.
(408)366-1000
ARCHITECT/ENGINEER.'
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Descri tion
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
P
with Section 7000) of Division 3 of the Business and Professions Cade, and my license is
in full tome and ef{�
RMDL KTCHN (16 0 SQ) BTH (9 0 SQ) &FAM RM
License Clan �(ffLk. N
r
Date �Contractor
OBARCHTrECrS DEcLARA N tC
I un d my plans shall be used as public records b U 1 C_ f�
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from iho Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or County
which requires a permit to rnnauvcL altar, improve, dcmolLch, or repair any strnetum
prior to its issuance, also requires the applicant for such permit to rile a sighed statement
Conuactoes License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrtom and the basis for the alleged exemption. Any violation of
,% 0 0 0 0
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more sham five hundred dollars (5500).
36913001.00
❑ 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 Conuwtor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employes, provided that such Improvements are not intended or otreted for sak 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
sak.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's L.I.
ccnsc Law does not apply to an owner or property who builds or improves thereon. and,
who contracts for such projects with a contractors) licensed pursuant to the Comraaoei
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner 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 performantm of the
work for which this permit is issued.
❑ I have and will maintain Worker's Cmnpenudon Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
'
My Workees Conpp��
sedlon iced riot be completed if the permit In. forone 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 California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Worker's Compensaition provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
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.)
'
Lender's Name
L r,ndees Address
I certify that I have read this application and state that rite above Information is
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cored I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize reprexnatives of this city to enter upon tM
above-mendonad property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilitiesjudgments, costs and expmsca which may In any way accruc againal said City
t of the granting of this permit.
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A
APPLICANTNT UNDERSTANDS AND WILL
MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hrrardom material
as defined by the Cupertino MunNaici Code, Chapter 9.12, and the Health and Safety
coda, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
3Yes
❑Yes
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 conuminanIs as Coed by the Bay Ames Air Quality Managemcnt
all new materials for inspection.
DtatricO
❑ Yes
I have read the hazardous materials requirements under Chapter 6,95 of the Cali for•
nia Health & Safety Code, Sections 25534.1 understand that if the building(.
-
does rut currently have a