09060019CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
19978
PERMl1' lSSUI! DATEOWNER'S NAME:
SAPHO
ARCHJTEcrIENGINEER:
BLDG ELECT PLUMB MOCH
ADD 210 S FT USING EXISTIN c=:J c=:J c=:J c:::J
BUILDING PERMIT INF
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~ B I hereby amrm l/Iollam licensed undcr provioions oCChapu:r 9 (commencing . , EXTER. Job Description
~ ~ :i1:u~a:n~~~~~iviSion3 oC the BusinC5Stand~ProCCSSI~.ons3Codef-' and my license il ~"~ ~. ~ ~ ~
~ 2:i License 91155 Lie, , -1-/ ' HL ~~ Dale ~-J .. " ARCHITEci?;~::;= VI rrk-<J
Ii! ~ I undcnlanll my plans shall be 05Cd u poblic rcconll
"'u
::: I;; Licensed ProCessional
':;:j OWNER-BUILDER DECLARATION
I hereby amrm thaI I am excmpt frum the COntraClOr's Liccn5c Law (or thel~ :i:co foliowing "",,,on. (Section 703 U. Busincss and ProCessions Code: Any cily or coonlY
• c> !l: which n:quiru a pc.nnil to construct, aJlef. improve. demolish. or repair illy struclu~j~ til prior III iu wuance. also n:quires the applicanl for soch permillO file a signed Slalement \--------==---;:;:--;::;;--7--------,-------__::;-:--;---:----+----:~~ that be islicenscll punuantto the provisions oCthe Conll1lCIOr's Licc .... Law (Chapter 9 Sq. Ft. Floor Area Valuation
':1:0 (commcnclng with Section 7(00) oC Division 3 oC the Business and ProC=ions C~) or
e~-that h. il ex.mpt thereCrom IIId the basis Cor lbe alleged exemption. Any violation oC I--------;-;:=~:;-__:;---------t_------=-----=--+-----
Section 7031.5 by any applicanl Cor. pennlt SUbje<:lS thc appliclllito a civil penalty oC APN Number Occupancy Type
nol more than five hundred dollars (S5OO).
21-~
D 1, .. owner oC tlie propcny. or my employees with wages as their sole compensation•
• ~tlie~~~~s~reil~~~~o~~~~~·~~t-----------------~-~·-d~~---------------+-----
IIId Professiorll Code: The ContnClOr's License: Law docs no' apply to III owner of
property who builds or improves thereon, and who does such work himadC or through hil
own employees, provided thai such improvemenlS are not inlCJldcd or offered for sale.lC.
how.ver, the building or improvemen< iJ sold within One year oC compl.tioa, IIIe owner-
builder wUI have the bunlen oC provingl/lol he did nOl build or improve for purpose of
sale.),
D I. as owner of the property, am exclusively eonll1lCling wilb licensed conll1lClOr> to
constnlClthe projec\ (Sec. 7044. Business and Professions Code:) The ConlnClOr'S U
eense Law docs nnl .pply 10 an owner of property who builds or improves thereon, and .
woo conUllcU Cor such projects with a conll1lC1OrtS) licensed porsuantlO the Conll1lClor's
Lic.... Law.
D J am exempt under Sec. • B &. PC Cor this rcsson
Owner WORKER'S COMPENSATION DECLARA~~N::------
I hereby aml1ll under penally of peljury nne oC the following decllll1lllnns:
D
3700 of the
for wbiclllhi5 permi' is issued.
'erand PoIicyn~_~ 9
Policy No.: ..5 -c:J _ ~==CiiiiRiiiGlJE~oiFF1EXEM5CEMPmON FROM WORKERS' I
COMPENSATION INSURANCE
(Thisscclion need not becompl.1<d iClhe permills foronehundrcd ~Uars (Sloo)
or less.)
I c:crtiC)' thol in Ibc perCormance oC the work Cor which this permil is wucd. I shall not
''''ploy Illy pemn in .ny manner so as 10 become sobJectlo the Workcl1' CompensationLaws oCCalifomia. DIll: _
AppIICIII'==::-:=-:-=--::---:---:-:--:-::-:~7'"--:-:::--:-----:--:-:NOTICE TO APPUCANT: If, after making lhi5 Ceniticale of Exemption. yoo should
Ix:com. subject 10 lbc Wortcr's Compensition provisions oC the Labor Code, you mUSl
fonhwith comply with such provisions or this pe",,;l shall be deemed revokcd.:>Zz8 CONSTRUCTION LENDINQ AGENCY-C/lE-oI hcmby amrm l/Iotthere il ,consuuclinn lending agency Cor the perCormance of a:>the work for which this permitls issocd (Sec. 3097, Civ. C.)UJlender's Name -------_ ~Cl Lendcr'sAddrcss _
:JZ
I certify thaI I hive read this "l'Plicalion IIId slate lhal the .bove information is
tl..-CDrn:CI. I aa= 10 comply wilb all cily IIId counl)' ordinances and SIal<: la.,s rcJ.tinglO
building conSUUCllon, and hereby authorin: reprosenlativcs of this Clly 10 enter upon lbc
UO
Ot) abovc-mcntioned propeny for inspection purpose..
(We) agree 10 save. indemniCy and keep harmless th. Cily oCCuperlino againsl _ C/l~~liabilities, Judgments, easlS and .xpenses who ay in any way acauc againsl said Cily
in 'onseqw:ncc o( the &riU1tin . nni
APPl.ICANT UNO OS AN LL COMPLY WITH ALL NON·POINT
SOURCE REG
UZ-6
MATERIALS DISCLOSURE
Will the appliClrl' or futun:: building occupantSIOn: or handle haunlous malCrial
as defined by the Cupertino Municipal Code. ChapleT 9.12, IIId the Health and SafelY
Code. Section 25532Ca)? ~
DYes /""0
Will the .pplicllli or fUUln: building occupant usc equipmenl or devices whieh
emil ha7..roous air eonlaminanlS u defincd by the BlY Area Air Qualily Managen\tnl
District1
DYes ~o
I have read th. hl7Mdous materills n:quirements ondcr Chapu:r 6.95 of th. CaIiCor
nia Health &. Safely Code, Sections 25505, 25533 anll25.534. I umlc=d that if the building
docs nOl currcnLly ha\lC I tenant. thal it is m . ilily to noLify Lhc occupant of the
n:quircmcnu which must . ISS a'IClte of Occuplllcy.
Owner or au
-C>
ReqUIre Inspections
Issued by: Date
Re-roofs
Type of Roof
All roofs shall De inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remov
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class ''11-'' or better