09020011 CITY OF CUPERTINO
BUILDING DIVISION PERMITt]� 'Ifl
BUILDING ADDRESS: PERMIT NO.
10327 VISTA KNOLL BLVD TIMELINE CONSTRTTrrPTON
"'WER'S NAME: PERMIT ISSUE DATE
PHONFANDRA MA & NEIL 90 14401 9;G BASIN WAY A-7 /W OGG9
E S A CONTROL NO.
(408) 711-3000
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z W with Section 7 f Di''on 3 of the Businese and Professions Cade,and my license is
boy in full force an ADD 189 3Q,BREAKFAST RM,EXTENSION OF KITCHEN &
j rM 2 License Class Lic.S b _�
Date L.' - i contractor
1187SQ KSTRBDRM, BATH, BATHROOM2-NO RE-ROOF & NO
uj RCHrrECTS DECLARATION
a< i understand my plans shall be used as public records STRUCTURAL
7yU
u.y Licensed Professional
'11.11
y OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
Coo following reason.(Section 7031.5,Business and Professions Code:Any city or county
e$rZ which requires a permit to convect,alter,improve,demolish,or repair any structure
y Zprior to its issuance,also requires the applicant for such permit to rile a signed statement
_< that he is licensed pursuant to the provisions of the contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 1 0 0 0 0 0
y r that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). 32613121 . 01
❑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(Sec.7044,Business Required Inspections
and Professions Cade:The Contractor's License 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.).
[11.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.
❑1 am exempt under Sec. B&P C for this reason
•er Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worket's Compen-
sation,as provided for by Section 37W 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 Worker s Compensation insurance caffie�3nd Policy number ate:
h )n !1�.0:510
Cartier r l J lolieyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
/ p V i k COMPENSATION INSURANCE
C r (This sseecti d riot be completed if the permit is for one hundred dollars(S 100)
or less.)
I certify that in the performance of the work for which this permit is issued.1 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
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONSTRUCTION LENDING AGENCY
[~.h wC.0)a I hereby affirm that there is a convection lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
a Q Lender's Name
Lender's Address
U 0 I certify that I have read this application and state that the above information is
W.[_' cortect 1 agree to comply with all city and county ordinances and state laws relating to
0 building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
Ow (We)agree to ve,indcmaify and harmless the City of Cupertino against
liabilities,judgments osis and expenses w may in anyway accrue against said City
V z in consequence of ranting of this pe ht Date f �
APPLICANT UN E STANDS AND 1 L COMPLY WITH ALL NON-POINT Issued by'.
SOURCE REG A ONS.
Re-roofs
Signature OrAfpTicant/cintracto Date T Of Roof
HAZARDOUS 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
he,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or lure building occupant use equipment or devices which If a roof i.;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminF....fialsmquircmc
defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes 1havemad haz on r Chapter 6.95 of the Califor-
nia Hcalth&Safct ode, 'ons 25505,25533 534 understand that if the building
does not curie have tenant,that it is ponsibi'y to notify the occupant of the
reyuiremen hch stbe-melpriorto' crtificateof pan Signature of Applicant Date
�te All roof coverings to be Class" j`'or better
Ow or prized agent Dare