09060031CY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10330 N WOLFE RD
OWNER'S NAME:
ARCHrrEcriENGINEER:
O p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
=wi W Section 7000) of Division 3 of the Business and Professions Code, and my license is
y in fun force and effect.
License Clan, Lic. s
F„ fate Contractor
ARCHITEC 'S DECLARATION
ccI understand my plans shall be used as public records
a0
0 Licensed Professional
5 1 hereby affirm OWNER -BUILDER DECLARATION
y that T am exempt from the Contractors License Law for the
Ct 00following reason. (Section 7031-5. Business and Professions Code: Any city or county
which requires a permit to eonstsucL alter, improve, demolish. or repair any structure
y prior to its issuance, also requires the applicant forsuch permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 700W) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violadon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($5M.
❑ L 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 (Sec. 7044. Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such worse himself or through his
own employees, provided that such improvements ere 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.).
L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec , B R P C for thi reason
Owner Date 7
, VO S COM S LARATION
I hereby al- ra rider penalty of perjury one of the following declarations:
❑ I have and will maintain a Certifimin 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit b 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 Ls for one hundred dollars ($100)
or less.)
I cenify that in the performance of the wort for which this permit Ls issued. I shall not
employ any person in any m n r so as
tobecome subject to the Worked Compensation
Laws of Califomia De
Applicant
NOTICE TO APP C� L after making this Certificate of Exemption, you should
become subject ro c- rkees Compensation provisions of the Labor Code, you must
O0 forthwith comply with ch provisions or this permit shall be dcemed revoked.
►
j CONSTRUCTION LENDING AGENCY
r ►-
-� 1 hereby air= that there is a construction lending agency for the performance of
4 7 the worst for which this permit is issued (Sec. 3097. Civ. C.)
a 0 Lender's Name
Z Lenders Address
0 I certify that I have read this application and state that the shove Information is
corccL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
v) liabilities, judgmens, toss and expenses which may In any way accmc against said City
Z in consequence of the granting o this permit.
�-' APPLICANT UNDERST ND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULA S
Signature of Appli tractor Date
US MATERIALS DISCLOSURE
Will the appl t or future building occupant snore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
El yes o
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
District? �N
❑ Yes l o
1 have read the hanrdous materials requirements under Chapter 6.95 of the Califor-
nia Health R Safety Code. Seen 25505. 25533 and 25534.1 understand ran if the building
does not cunemly ha �c a n is my responsibility to notify the occupant of the
requirements which m ct p)sor ja i snancc of a Ccniflcatc of Occrropanry
T CONSTRUCTI
(408) 234-4340
PATIO DEMO (700SQ)
Sq. Fr.. Floor Area
PERMIT NO.
PERMIT ISSUE DATE
S A CONTROL NO.
BUILDING PERMIT INFO
BLDG EIECr PLUMB MECH
Job Description
-Valuation
APN Number Occupancy Type
31620052.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date ( - (-( (lam
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
Owner or
All roof coverings to be Class".. ' or better