09120142CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10382 SCENIC CL
CONTRACTOR: TBD - TO BE
PERMIT NO: 09120142
DETERMINED
OWNER'S NAME:
PHONE NO:
2r LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL 11 COMMERCIAL
License Class Lic. #-���.
REMODEL -STRUCTURAL 246 SQ FT TO KITCHN (M,E,P)
Contractor
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
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
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $25000
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 35707024.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. 1 agree to ply with all c' and county ordinances and state Taws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building cons cti n, and hereb a orize representatives of this city to enter
upon the above nti ed prope for spection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and'- p h less the ity o upertino against liabilities, judgments,
costs, and expen s w ich may a rue ag 'nst said City inconsequence of the
--�
Issued by�/ Date: G
nderstands and will comply
granting of this p rm'
Municipal Code, Section
9.18.
�RE-ROOFS:
Signature G%
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.
❑ OWNER -BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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 & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
I hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cu lino Muni i al Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25 3 a) shoul I tore or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should I e uipme t o ces which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by th B Area I a ty Management District I
performance of the work for which this permit is issued.
will maintain compliance with the ertin i 'p Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sec '
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorized agent: Date: -La --o
_
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 Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION L NDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree toc ply with all city and county ordinances and state laws relating
to building on ti n, and hereby orize representatives of this city to enter
upon the above nti ned property or i spection purposes. (We) agree to save
indemnify and k p h less the C ty o upertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expen s ich may ac a ag 'ns iN City in consequence of the
I understand my plans shall be used as public records.
granting of this p rm . Addie p can derstands and will comply
with all non-poin s rce r 1 'o s per upe o Municipal Code, Section
Licensed Professional
9.18.
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Signature Date12