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CITY OF CUPERTINO
PERMIT
BUILDING DIVISION
BUILDING ADDRESS:
PERMrr NO.
21438 KRZICH PL
TBD - TO BE DETERMINED
07080115
OWNER'S NAME:
PERMIT ISSUE DATE
:
SANITARY NO. CONTROL NO.
ARCHITEGTIENGINEEIL,
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby licensed Chapter 9
Job Description
affirm that I am under provisions of (commencing
with Section 700a) of'Division 3 of the Business sort Professions Code, and my ticeirs: is
ADD 246,MASTERSUITE, LIVING RM-EMODEL 2306 ENTIRE
in full force and drat
LleenscCiass L.ie.#
HOUSE -REMODEL KITCHEN, FAMILY RM, DINING
Date Contractor
ARCHr1EMDECLARATION
RM, BATHROOMS, LIVING RM NEED METER
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am eXaMpt from the Contractors License Law for the
following reason. (Section 7M 1.5, Business and Professions Code: Any city or county
which requites a permit to construct, aher, 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 to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
(commencing with Section 7000) of Division 3 of the Business$ and Professions Code) or
2 8 5 0 6 5
that he is exempt therefrom and the basis for the alleged exemption. Any violadcrt of
Number
AFF
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil prmity or
net more than five hundred dollars (SM
3 6 2 0 6 0 3 8
❑ 1, as owner of ttie property, or my employees with wages as their sole compenutiom,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code The Contractors License Law don not apply to an owner of
proplerity who builds or improves demon, and who does such work hi —if or through his
mm employees, provided that such improvements am nol intended or offered for sale If.
however. the building or improverne . 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.).
0 L as owner of the property, am exclusively contracting with licensed contractors to
Eonstnut the ptojW (See. 7044, Business and Professions Code.) The Contractors Li-
cense Law does not apply to an owner of property who Indicts or improver thereon, and ,
who contracts for such projects with a crintratum(s) licensed pursuant to the co amacies
License Law.
1 am exempt under See B & P C f this ressam
Owner Date 11 2%
ORIMRtrPENSA71ON DECLARATION
I hereby arm under y of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to W f--iasum for Workers Compen•
cation, as provided for by Section 3700 or the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of die work for which this permit is issued
My Worker's Compensation Insurance artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF R—EmpnON FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is for one hundred dollars ($100)
or less)
1 certify that in the performance of the work for which this permit is issued,) shall not
employ any person in any
NOTICE TO APPL I alter making ifis CeWftate 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
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lenders Name
Landers Address
I certify that I have read this application and stale 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 authodne rcpresenadm of this city to enter upon the
above -mentioned property for inspection Porprres
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of the granting or this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
° Date
US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hreardous material
as defined by the Cupertino Municipal Code. Chapicr 9.12. and the Health and Safety
Code, O� 25532(a)? 1!K
All roofs shall be inspected prior to any roofing material being installed.
Will
If a roof is installed without first obtaining an inspection,agree to remove
the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
.1
all new materials for inspection.
District? •
❑Yeslo
Ihaveriddie ha udousmaterialsmquimmemsumlerChapter6.95oftheCalifor-
niaHealth&SafetyCode,Sectiw1S5M.25533low25534.1understandthatirthe building
does not cunemly have a harem. the it is my responsibility to no,ify die oceupam of die
requirementsw metpriorto'
_. _.
Date