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09010081.7C Z E"h 4 tYi � a� �z UC w E �a a Uz CITY OF CUPERTINO DIVISION PERNIIT1''T'C����''�� BUILDING BUILDING ADDRESS: PERMIT NO. 10100 N STELLING RD HAMMOND OWNER'S NAME: PERMIT ISSUE DATE PHONE: A CONTROL NO. (408)255-9994 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description P I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code. and my license is in fall fora and effect. COWL TI INCLD HANDICAPPD ACCESSBLTY UPGRDS NEW License class Lk. X Date Contractor HVAC, LIGHTNG, CEILNG GRID 6059SQ ARCHITECTS DECLARATION I understand my plans shall he used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors 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 that he is licensed pursuant oo the provisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 2 O O O 0 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 (SM. 32631019 .00 ❑ L as owner of the property, or my employees with wages as their sole compensation. e Required Inspections will do the work, and the structure isnot intended oroffered for sale (Sec.7au,Business and Professions Code: License The Contractors Licee 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:) TIC Contractors Li- cense Law does not apply to an owner of property who bolds or improves thereon, and • who contracts for such pmjecs with a contractor(s) licensed pursuant to the Contractors License Law. ❑ I am exempt under Sec B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -inure for Worker'sCompen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ 1 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 EXEMP ION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed If the permit is for one hundred dollars ($100) or leas.) 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 the Workers' Compensation Laws of California. Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should became subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shale be deemed revoked I cONsmucnON LENDING AGENCY I hemby affirm that there is a construction lending agency for the performance of the work for which this permit Is issued (Sec. 3097. Civ. C.) Lenders Name Lender's Address I unify that i have read this application and state that the above information is correct 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 above -mentioned property for inspection purposes (Wc) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments. cots and expenses which may in any way accrue against said City in consequence of the granting of this permit APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT Issued by: Date SOURCE REGULATIONS. Re -roofs Type of Roof Signature of Applicant/Contractor Date HAZARDOUS MATERIALS DISCLOSURE 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 Code. Section z553z(a)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes ❑ No 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 read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant, cast it is my responsibility to notify the occupant of do requirements which must be met prior to issuance of certificate of occupancy. . Signature of Applicant Date All roof coverings to be Class'n " or better Owner or authomrd agent Date . n CITY OF CUPERTINO BUILDING PERMIT ( 4C-30 kL BUILDING ADDRESS: 10100 N STELLING RD BLDG 1 CONTRACTOR: HAMMOND HOMES PERMIT NO: 09010081 ENTERPRISES OWNER'S NAME: ABUNDANT LIFE CHURCH 6611 JOHN DR DATE ISSUED: 07/01/2009 OWNER'S PHONE: 4082522668 CUPERTINO, CA 95014 PHONE NO: (408)255-9994 LICENSED CONTRACTOR'S DECLARATION I— r License Class__ Lic. # 70 3 BUILDING PERMIT INFO: BLDG ELECT PLUMB MECH RESIDENTIAL COMMERCIAL Contractor Date 14) a I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:COM'L TI-BLDG 1 MAIN CHURCH INCLD (commencing with Section 7000) of Division 3 of the Business & Professions HANDICAPPD Code and that my license is in full force and effect. ACCESSBLTY UPGRDS NEW HVAC, LIGHTNG, CEILNG GRID 6059SQ I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self -insure for Worker's [ �/ISIp rv' VLSe "i v\G[OW i t)e 0.4 Lon Compensation, as provided for by Section 3700 of the Labor Code, for the- perfbnnance of the work for which this permit is issued. 7 J I have and will maintain Worker's Compensation Insurance, as provided for by Sq. Ft Floor Area: Valuation: $200000 Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION APN Number: 32631019.00 Occupancy Type: I certify that 1 have read this application and state that the above information is correct. 1 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 above mentioned property for inspection purposes. (We) agree to save PERMIT EXPIRES IF WORK IS NOT STARTED indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR granting of this permit. Additionally, the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION. with all non -point source lations per the Cupertino Municipal Code, Section 9.18. 57 Date ZO 09 / Issued i Date°G- —?�' Signature v� ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of ROOFS: All roofs shall be inspected prior to anyy ro roofing material being installed. If a roof is the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, installed without first obtaining an inspection, I agree to remove all new materials for will do the work, and the structure is not intended or offered for sale (See.7044, inspection. Business & Professions Code) Signature of Applicant: Date: I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 1 hereby affirm under penalty of perjury one of the following three declarations: 1 have and will maintain a Certificate of Consent to self -insure for Worker's HAZARDOUS MATERIALS DISCLOSURE Compensation, as provided for by Section 3700 of the Labor Code, for the I have read the hazardous materials requirements under Chapter 6.95 of the performance of the work for which this permit is issued. California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain 1 have and will maintain Worker's Compensation Insurance, as provided for by compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Section 3700 of the Labor Code, for the performance of the work for which this Safety Code, Section 25532(a) should I store or handle hazardous material. permit is issued. Additionally, should I use equipment or devices which emit hazardous air 1 certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the not employ any person in any manner so as to become subject to the Worker's Health & Safety Code, Sections 25505, 25533, and 25534. Compensation laws of Califomia. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, 1 must ON a, orize gent: forthwith comply with such provisions or this permit shall be deemed revoked. Date: APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's correct. 1 agree to comply with all city and county ordinances and state laws relating for which this permit is issued (Sec. 3097, Civ C.) to building construction, and hereby authorize representatives of this city to enter Lender's Name upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, Lender's Address costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section ARCHITECT'S DECLARATION 9.18. I understand my plans shall be used as public records. Signature Date Licensed Professional