08070022CITY OF CUPERTINO
�� min W.. >
BUILDING DIVISION PERNIIT
BUILDING ADDRESS:
PERMIT NO.
20571. & 20573 SCOFIELD DR
TBD — TO BE DETERMINED
08070022
OWNER'S NAME:
PERMIT ISSUE DATE
:
SANITARY NO, CONTROL NO.
ARCHrECi/ENGiNEER:
BUILDING PERMIT INFO
2 STORY SFDWL W/PORCH
o 0 0 0
LICENSED CONTRACTOR'S DECLARATION
3,66t,r
] senption
l hereby affirm that I am licensed under provisions of Chapter 9 (commencing
- - - ' . - - _-- _—
with Section 7000) of Division 3 of the Business and Profcssiuru Code, ad my license is
in full fume and effect.
Lkmr= class _ Lle. 0
Date Coniraetor
ARC;TTECrS DECLARATION
I urKkuVand my plans shall be used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alarm that 1 am exempt from the Contractor's L3censo Law for rho
following nsson. (Section 7031.5, Business and Professions Cods; Any city or county
which requires a permit to construct, alter. Improve. demolish, or mpair any structure
-
prior to its issaarcc. also requires the applicant for such permit W file a signed statement
that he is licensed pursuant to the provisions of the Contractors Llanm Law (Chapter 9
-
Sq. Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt tbadrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
anc
P Y Type
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollarssoo).
(s
❑ L se. owner of the property, or my employes with wages as their sole eonpermulon,
Required Inspections
will do the work. and the swclure is not intended or offered for sale (Set. 7044, Business
and Professions Code The contractors License Law does not apply to an owner of
property who builds or impro d thereon, and who does such work himself or through big
wen employee, provided that such improvements axe 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 dual or improve for purpose of
ale.).
[3' L a owner of the property, arm exclusively contracting with Iksmsed conuactors in
coruuuct the project (Sec. 7044. Business am Professions code:) The contractors Li-
cense Law does not apply to an owner of property who builds or improves the and,
who cataracts for such ptnjeus with a contractor(s) lictrtsed pursuant to the Comracwr's
License Law.
❑ 1 am
I hereby affirm under penalty of perjury arc of the following declarations:
❑ 1 have and wM maintain a Certificate ofConsem. to self -insure for Worker's Compen,
radon, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Waders Compensation Insurance, as required by Section
3700 of the Labor Coda for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section Treed not be complexd if the permit is for one hundred dollar (ilOf))
mr less,)
,
I certify dial In the performance of the work for which this permit Is Issued. I shall mm
employ any person in any, mean subjm to the Workers' Compensation
Laws of
, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C)
Larders Name
Lenders Address
1 artily that I have mad this application and state that rho above information is
correct 1 agree to comply with all city tad county ordinances and state laws relating to
building construction. and hereby authorize representatives of this city to enter upon the
above-mendwed property for inspection purposes.
(Wei) agree to save, indemnify and keep harmless the clry of Cupertino against
liablIldes, judgments, cosu and expenses which may in any way accrue against said City
in uence of the ng of this PCrMiL
APPLICANT UNDERSfmANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE
Will the applicant or future building occupant store or he larudous material
as cleared by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Coda, section 25s32(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes VNO
If a roof is installed without first obtaining an inspection, I agree to remove
will the applicant or fuum building orzvpant use equipment or devices which
emit hazardous air contaminants as dented by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yea
I have mad the hazardous materials nxpdmncnss under Chaper 6.93 of the Callfor-
nia Health & Safety Code, Sections 2M.75533 and 25534.1 urndeaud that If the building
don not twrently have a reran. 0tat it is my responsibility to notify the occupant of the
ream u which mxnrbe me` oa cerrircate ova (
Signature of Applicant Date
All roof coverings to be Class "/ " or better
Own orwtltorizcdagent Date