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CITY OF CUPERTINO7777-77
01
BUILDING DIVISION PF,IIT
BUILDING ADDRESS:
PERMIT NO.
10535 FELTON WAY
MATTHEW SOMMER
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S A 9 9 CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and affect
DEFERRED &REVSN ROOM ADD & RMODEL ; ORIG #08120140
License Class Lic. N
Dale Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance- also requires the applicant for such permit to file a signed statement
Contractor's ULcrrsa 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
$499
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
35918011 .00
❑ I, as owner of the property, or my employees with wages as their sale compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
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 employers, 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 -
b ' ' 1 have the burden of proving that he did not build or improve for purpose of
sale.)
. a ner of the property, am exclusively contracting with licensed contractors to
Th
construct the project (Sec. 7044, Business and Professions Code:) e Conuactors Li -
cense Taw docs 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 Convector's
License Law.
❑ I am exempt under Sec , B & P C for this mason
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 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 m ' l -Workers Compensation Insurance, as required by Section
3700 of the Labo for the performance of the work for which this permit is issued
'
My Worker's top n nee carrier and Policy number are:
Carrier. Policy No.:
LATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far 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 so as to become subject to sere Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation 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 whicb this it ' -sued (Sec. 3097, Civ. C.)
Lendee: Nam-
,
Lenders Addrr3
,
i1 cert fy at I h -read tris application and stale Drat the above information is
i correct. 1 agree to ly with all city and county ordinances and state laws relating to
i building construction, and hereby authorize representatives of this city to enter upon the
ahave-mentioned property for inspection purposes
(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
' in consequence of the granting of this permit
' APPLICANT UNDE TANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGUL N
_17& iRe-roofs
C '
Type of Roof
Signature of Applican ntractor date T_
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici Code- Chapter 9. 12, and the Health and Safety
Code, 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
El Yes No
El Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant useequipment or devices which
emit hazardous air contaminants as dcfrncd by the Bay Area Air Quality Management
all new materials for inspection.
District? it
❑ Yes ❑
I have read the hazard s materials requirements under Chapter6.95 of the Califor-
niaHcalth&Safety Codc, "togg 25505, 25534.1 understand that iftrc building
does not currently h�is my responsibility to notfy tre occupant of tre
rcyuircmenisw icTi rssaane-ora Certificate of oad:apancy. /,
Signature of Applicant Date
iV
All roof coverings to be Class "A},' or better
g
Owner
or au ant ate