09040064 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT � �
BUILDING ADDRESS: PERMIT NO.
18841 PENDERGAST AVE JOSEPH CHOU 09040064
PERMIT ISSUE DATE
'WNER'S NAME:
A O. 0 0 9 CONTROL NO.
BUILDING PERMIT INFO
ARCHTTECTIENGINEER:
BLDG ELECT PLUMB MECH
Q p p LICENSED CONTRACTOR'S DECLARATION Job Description
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z ul with Section 7000)of Division 3 of the Business and Professions Code,and my license is S FDWL NODULAR STRUCTURE 1, 858 ' PORTION OF IT
=H in full force and effect
-z License Class Lle.# CONVENTIONAL FRAME CONST (122 ' ) —GARAGE 426 '
3 F -p Date ARCHITECTS DECLARATION
J�U 1 understand my plans shall be used as public records CONVENTIONAL FRAME CONST.
uu..f- Licensed Professional
C< OWNER-BUILDER DECLARATION
vi
1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
Km 9 which requires a permit to convect.alter,improve,demolish•or repair any structure
n Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft. Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $120000
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500). 37533024 . 00
❑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 forsalc(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of Q p
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.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.).
®'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 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.
01.
DECLARATION
I hereby ifffirm under penalty of perjury one of the following declarations:
❑I 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.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need riot 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 as become subject to the Workers'Compensation
Laws of California.
Applicant
Certificate of Exemption,you should
become subject to the o 'res Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z 2CONSTRUCTION LENDING AGENCY
[~-t rN+ I hereby affirm that there is a construction lending agency for the performance of
(yrthe work for which this permit is issued(See.3097,Civ.C.)
W Q Lendces Name
�Z Lcndees Address
V C) I certify that I have read this application and state that the above information is
LL correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building convection,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (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
U'Z in consequence of the granting of this permit. Date —Q
�+ APPLICANT
�/ Re-roofs 2--�
Signatureol'App onuactor Data
MT Of Roof MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
ode.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Vo
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 contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 15534.1 understand"if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements wh' m be met pfi 10' of a Certificate of Occupancy. Signature:of Applicant Date
All roof coverings to be Class'JW'or better
Owner or authorize c Date