08070210 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ' � �� `
PERMIT NO.
BUILDING ADDRESS:
10210 PENINSULA AVE TBD — TC BE DET I
PERMIT ISSUE DATE
^WNER'S NAME:
SXWA CONTROL NO.
PHONIry T N zT my T
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
Z p p LICENSED CONTRACTOR'S DECLARATION Job DCSCTIptlOn
U 5 I hereby affirm that I am licensed under provisions of Chapter 9(commencing
m with Section 7000)of Division 3 of the Business and Professions Code.and my license is ADD LVRT I,D INERM,FAMRM&MS TRBTH(7 2 7 S Q)&4 4.1 SQ
. in full force and effect
i-Z License Class Contractor GARG r•NO
Date
ARCHITECTS DECLARATION STRCTRL
understand my plans shall be used ss public records
�yU
4 y Licensed Professional
y 3 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
a O following reason.(Section 7[!31.3,Business and Professions Code:Any city or county
e,0, which requires a permit to conswct alter,improve,demolish,or repair any structure
y14 prior to its issuance,also requires the applicant for such permit to file a signed statement q Ft.Floor Area Valuation
F4< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
E F=-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $160000
U_� that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). 3262201" . 00
0 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(See.7044,Business Required Inspections
and Professions Code:The Contractor'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 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-
bui r will have the burden of proving that he did not build or improve for purpose of
sa
as owner of the property,am exclusively contracting with licensed contractors to
consswct 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.
C]1 am
[
I hereby affirm under penalty of perjury one of the following declarations:
Q 1 have and will 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.
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 Workers 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 for one hundred dollars(S 100)
or Icss.)
I certifyThat in the perflo 'ma of the work for w h this permit is issued,I shall not
employ any
CcrtiGrate of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed mvokcd.
Z 0-4 CONSTRUCTION LENDING AGENCY
(�rte. I hereby affirm that there is a construction lending agency for the performance of
ar 5 the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lenders Name
Z Lenders Address
V C) I certify that I have read this application and state that the above information is
Li~ correct I agree to comply with all city and county ordinances and state laws relating to
0 U building construction.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
rA liabilities,judgments,costs and expenses which may in any way accrue against said City y
V Z in consequence of the granting of this permiL Date
►� APPLICANT UNDERSTAN NO WILL COMP WITH ALL NON-POINT Issued b):
SOURCE
UREC T 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(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof .s 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? -
0 yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& cry Code,Sections 25505.25533 and 25534.1 understand that if the building
does not cu nt have a tenant that i s my responsibility m notify the occupant of the
requiremen w h must be met prior issuance of a Certificate of oopancY., Signature.of Applicant Date
IAI All roof coverings to be Class';."or better
Ow r or autho .d agent - Dare