07100017 CIT�' OF CUPERTINO ' > " ' '
BUILDING DIViS10N PERMIT ��.1�R����C?� ���R��4TI�N '
BUILD D g, ESS: PERMIT N0.
���SU MC CLELLAN RD FLORY "ONSTRUCTION INC. 07100017 •
R'S NAME: PERMIT LSSUE DATE
NE�� LIFE CHURCH OF NAZARENS 232 V ERNA CT
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUtLDING PERMITMFO
TRUS S �ALC S BLDG ELECT PLUMB MECH
� � � 0
i o p LICENSED CONTRACfOR'S DECLARATION JO17 DeSCilptl0❑
: V� I hcrcby aflirm that I am ticcnscd undcr provisions aC Chaptcr 9(commcncing
; Z� with Secdon 700U) of Division 3 of thc Businccc and Pro(cssions Codc, and my liccnx is
�� y in fuil foree and effe �
�� Z Licensc Clazs �' �. k •
: F ,p DatcT�ConincWr ' 0 2 C o�' b ? iNG.
� AI�CHiTECI'S DECLARATI
7� a 1 undcrstand my plans shall bc uscd as public rccords
)qU
` u. � Liccnsed Profcssional
� y � OWNER-BUILDER DEC(.ARATION
1 hcrcby alTirm �hat 1 am cxcmpt Crom �hc Conuactor's Liccnsc Law far tt�c
� p O lollowing r; uon. (Scction 7031.5, Busincss and Profccsions Calc: Any city or coun�y
�,°, � which rcquires a pctmit to cnnswct, altcr, improve, dcmolish, or rcpair any suucturc
° z y prior ui i�s issuancc. alsu m,quires thc applicant far such permit �o filc a signed sta�cment Valuation
y � �hat he is IiccnscJ pursuant to lhc provisions of thc Convacu�r's lic�cnsc Law (Chaptcr 9 Sq. Ft. Floor Area
� t- (commencing with Scction 7000) of Division 3 of Ihc Busincss and Profcssions Codc) or
y�� that he is exempt themfrom and tAe buis for the allegcd exempuon. Any violarion o(
Secuon 7031.5 by a�ry applicant tor a pertnit subjecu �he applicant to a civit pcnalty of APN Number Oecupancy Type
nat mare than five hundred dallazs (5500).
❑ I, u owner of ttrc propccty, ar my employces with wages u their solc compensaUon,
wil! do �hc work, and the structure is nat intended a of[ered (or sa� (Sec. 7044. Husiness Re u ired Ins eCtl Oi1S
and Professions Code: The Conuactor's Licenu Law docs not appiy to an owner af 9 P
prapeny who builds or improva thercon, and who daes such work himself or through his
own employccs, providcd ihat such improvemenls are noc intcnded or oliered for sala I[.
however, the building or improvement is sold wi�hin one year of complction, d�e owner-
builder will have the burden o[ ptoving that he did not build or improvc [or putpose o(
salcJ.
❑ I, as owner o[ the propeny, am uclusively coNracting with licensed rnnvacmrs to
construct the projea (Sec. 7044. Business and Profcssions Code:) The Contracmr's Li-
ccase Caw dacs not apply to an owncr of propeny who builds or improves �he�eon, and , ,
who wnuacts Cor such projecLt with a conuactor(s) licensed pursuant to �he Contractors
Licenae Law.
n I am uempt undu Sec. , B& P C for this reason
:r Date _ . _
WORKER'S COMPENSAT[ON DECLARATION
1 hercby affimi under penalty of pe�jury nnc of �he following declaratians:
❑ I hs.�e and will maintain a Cenificmc ot Conscnt to sel(-insum for Workcfs Compen-
ution, as providcd for by Sec[ion 3700 of the Labor Code, for the pedortnancc ot thc
wark for which this permit is issucd.
❑ I havc and will main�ain Worker's Compensation Insurance, u rcquired by Scction
3700 0( thc Labor Codc, Cor thc performancc of the work for which this permit is issued.
My Worke�s Compe�ation Insurance cartier and Palicy number are:
Cartier: �. iG�t .e,�._ ��,, ry No.: �� �
yr CE�RI7FICATE dF ON FROM WO�EAS'
COMPENSATION INSURANCE
(fhis section need not be completeJ if iAe permit is ku one hundced dollars (S 100)
ar IcssJ '
I cenify that in thc performancc of ihc wark for which ihis pertnit is issucd 1 shall not
e�ploy any person in any manner so az w become su6ject to Ihe Workers' CompensaUon
Laws of Cali(omia. Datc
Applicam
NOTICE TO APPLICANT: if, alYcr making this CcrtiGca�c ot Excmption, you should
bccome subjcct to ihe Worker's Compensation provisions of �c Lalwr Codc, yau mus�
� O foMwiih comply with such provisions or this pertnit shall6c dcemed n.waked.
Z '"" CONSTRUC'IION LENDWG AGENCY
(—�i � 1 hereby aQirm �hat there is a consuuction Iending age�y Cor the perCortnance of .
a� ihc wurk fur which ihis permi� is issucd (Scc. 3097, Civ. C.)
a A Lendcr's Namc '
a z L.cader's Address
U � I certi[y that 1 havc rcad this application and staic that Utc abovc infortnatiun is �
� �"' correc� 1 agrce a comply with all city and county onlinances and sute laws rclating to
.J U building conswction, and hcreby authori�e rcprcuNativcs of this ci�y to cntcr u�n thc
� W abovc-mcnuoncd property for inspcction purposes.
a (We) agrce �o save, indemnify and kecp harmless ihc City aC Cuper6no against
H � IiabiliUu, judgmcn�s, costs and expcnscs which may in any way accnx against said City
U z in consequcnce of U�c granting o[ ihis permit. Date `���� �
►-� APPLICANT UNDER ANDS AND IL OMPLY WITH ALL NON-POINT Issued by �
SO�1R�E REGULA
� ��'"'��`�7 Re-roofs �.—�
S' awm of Appli UConuact r Da�e T of R oof
HAZARDOUS MATERIALS DISCLOSURE }��
�11 ihc applicant or futurc buitding occupant storc or handlc ha�ardous matcrial
lefincd by Ihe Cupenino Municipal Codc. Chaptcr 9.12, and the Heal�h and SaCety
.c.Sec�ion25532(a)? All roofs �hall be inspected prior to any roofing material being installed.
�y� �'No ,
�II thc applicant or futurc building accupant usc cyuipmem or dcviccs which If a roof i� installed without first obtaining an inspection, I agree to remove
cmii harardaus air contaminantc az dcfincd by the Bay Area Air Quality Managcmcni all new m aterials for inspec*ion.
oisvk�?
❑ Ycs �Nu
l havc rcacl �he hvardcws ma�crials rcquircmcnts undcr Chap�cr 6.95 of �c Califor-
nia Hcal�h & Safcty Codc, Sccuons 25505, 25533 aru125534. f undcrstand �hat iCUic building
docs not cwrcntly havc a tcnan4 �at it is my rosponsiAility w nou(y thc occupant af Ihc
rcyu' nlswhichm m« a<< � c�rir�a�ora���r. gignature ofApplicant Date
d ` —'� All roof coverings to be Class "B" or better
O �rt or authorizc agcnt ���