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08030001 CITY OF CUPERTINO BUILDING DIVISION PERMIT 'h��'�� la BUILDING ADDRESS: . ...,•,••, ., PERMIT NO. 10619 LA RODA DR VARAS CONSTRUCTION OWNER'S NAME: PERM[rr ISSUE DATE PHONE: S CONTROL NO. (650) 207-9630 ARCHI'lECrfENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH u O p LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z with Section 7000)of Division 3 of dee Business and Professions Code,and my license is ?'Zc y in full force and effect. DEFERRED TRUSS CALC S iLicense Class L.ic.0 ;,a Date Contractor 3/03/08 SEE NOTES ARCHITECTS DECLARATION 1 understand my plans shall be used as public records 5 U Licensed Professional n y OWNER-BUILDER DECLARATION t I hereby affirm that 1 am exempt from the Contractor's License Law for the %0 Oa following mason.(Section 7031.5,Business and Professions Code:Any city or county '4 e ,�,li which requires a permit to construct,alter,improve,demolish,or repair any structure n Z y prior to its issuance,also requires the applicant for such permit to file a signed statement < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation Y (commencing with Section 7000)of Division 3 of the Business and Professions Code)or that he is exempt therefrom and the basis for the alleged exemption.Any violation of 83500 Section 703"by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(550(} 36933028 . 00 ❑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 We(Sex.7044,Business and Professions Code:The Contractors License Law dors not apply to in owner of Required Inspections property who builds or improves thereon,and who does such work himself or through his awn 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.). ❑1,as owner of the property,am exclusively contracting with licensed convectors to construct the project(Sec 7044.Business and Professions Code:)The Contractor's Li. cease Law does not apply to an owner of property who builds or improves thereon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. [:]I am exempt under Sec ,B&PC for this reason Owner Date WORKERS 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 Worker's Compen- satlon,as provided for by Section 3700 of 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 dee Labor Code,for the performance of the work for which this permit is issued. My Workers Compensation Insurance artier and Policy number am: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed lithe permit is forone hundred dollars($100) or las) 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 become subject to the Workers Compenuflon provisions of the Labor Code,you must 0 Z forthwith comply with such provisions or this permit shall be deemed revoked. 'Z O CONSTRUCTION LENDING AGENCY [�nC.41-i 1 hereby affirm that there is a construction lending agency for the performance of L7!.> the work for which this permit is issued(Sec.3097,Civ.C.) Own Q Lenders Name , Z L.endersAddress V C I certify that 1 have read this application and state that the above information is W.t"' correct-I agree to comply with all city and county ordinances and state laws relating to OV building construction,and hereby authorize representatives of this city to enter upon the F ashove-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against ,..i fo2 liabilities,judgments,costs and expenses which may in any way accrue against said City V Z in consequence of the granting of this permit. -+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATIONS. Signature of Applicant/Contractor Dare Re-roofs -- HAZARDOUS MATERIALS DISCLOSURE Type of Roof 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 2553z(a)? ❑Yes El NO All roofs shall be inspected prior to any roofing material being installed. Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes F1 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,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a certificate of Occupancy. Signature of Applicant Date Owner or authorized agent Date All roof coverings to be Class'n"or better ()M CITY OF CUPERTINO CUPERTINO REVISION/DEFERRED PERMIT APPLICATION FORM APN # n �O b Date: 0 3 © f Original Permit #: O 7/ ©o Qb V Building Address: /o0// Cl ,Z 7q Mailing Address (if different from building address): Owner's Name: Phone #: Contractor: Phone: 6�5-0 Fax: Contractor License #: / Si 7 Cupertino Business License#: 2of7 Contact: Phone: `��/L Fax: Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Residential Commercial ❑ Job Description: Type of Construction (Usage Class): * Occupancy Type: 1 FR, 11FR ❑ 11, 111, V-IHR ❑ 11, 111, IV V-N lZ Valuation (cost of project): Project Size: Standard Large ❑ Major 7 Valuation: ,W CITY OF CUPERTINO CUPERTINO REVISION/DEFERRED PERMIT APPLICATION FORM FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type Sq Ft 1REVCOMNEW Revision Commercial New B 1* 1REVCOMTI Revision Tenant Improvement B 1* TI 1REVSFDWL Revision SFDWL B 1R3SFDW 1REVRESADD Revision Addition B 1R3SFDADD 1 REVRESREM Revision Remodel B 1R3SFDREM 1DEFINSP Deferred Submittal not R-3 B 1* Ins ection 1DEFPLNCK Deferred Submittal not R-3 Plan B 1* OR Check 1DEFR3PLNCK Deferred submittal R-3 Plan Chk B 1R3SFDW IR3SFD D MSFDREM 2of3