08100144CITY OF CUPERTINO�h7�k1�la,�11T �u "rye ' Ur
BUILDING DIVISION Pr,lYFi k
BUILDING ADDRESS:
PERMIT NO.
21979 SAN FERNANDO AVEB&B CONCRETE CONSTRUCTION npinn144
OWNER'S NAME: CIO PERMIT ISSUE DATE
PHO CONTROL NO.
VIA DTA
(408)279-2277
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MFrH
a o pLICENSED CONTRACTOR'S DECLARATION
; tip, K I hereby affirm that I am liconsed under provisions of Chapur 9
=� y in full force and effect
3 g Z License Clan Lie. 0
F p Date Contractor
ARCHITECTS DECLARATION
1 nnileb•nd my plans shall be used as public records
4 O y Ucensed Professional
yOWNER-BUILDER DECLARATION
1 bcroby affirm that I am exempt from the Contractor's License Law for the
p o following mason. (Section 70313, Business and Professions Code: Any city or county
m which requires a permit to construct, alter, improve, demolish, or repair any structure
a Z y prior to its issuance, also requires the applicant for such permit Lo file a signed statement
= G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more 111311 five hundred dollars (5500).
❑ L as owner of die 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
and Professions Code: The Contractor's License Law does not apply 10 an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements ate not inthmded 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 dust he did not build or improve for purpose of
sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:)The Conuacars U.
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 plmwam to the Contnaors
License Law.
❑ Ism In under Sec. B & P C for this MasonZ
Owner Date - o v,
WORKER'S COMPENSAIJgN DECLARATION
1 hereby affirm under penalty of perjury one of the following ekclarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Cede, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
cornmCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rat be completed U the permit Is for one hundred dollars ($100)
or less)
1 certify that in hbe performance of the work for which this permit is issued 1 shall nes
employ any person inany mann r so as come subject to the workers' Compensation
Laws of Cal(fo is Date
Applintut
NOTICE TO APPLICANT: If, after making the (CcrjftczLc of Exemption, you should
become tubjea a the Workds Compersaton prov ons of the Labor Code, you must
.J Z forthwith comply with such provisions or this pewit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby drum that tare is p construction lending agency for the performance of
Ri > the work for which this permit is issued (Sec. 3097, Civ. C.)
aQ Lenders Name
] Z Lenders Address
V 0 1 certify that I have read this application and state that the above information is
LL ^ coma. I agree to comply with all City and county ordinances and state laws relating to
0U building conswction, and hereby authorize representatives of this city to enter upon the
Wabove-mentioned property for inspection purposes,
against
(We) agree to save, indemnify and keep harmless the City of Cupertino 0.►�-h rA liabilities,jhdgmens, costs and expenses which may in any way accrue agdast saidty
d QCity
V 'Z in consequence of the granting of this permIL
■^ APPLICANT UNDERSTANDS AND XJJ.L COMPLY WITH ALL NON -POINT
SOU REGULATIONS.
i ty ey
Signature of ApplianUConuactorDale
HAZARDOUS '.IALS DISCLOSURE
Will am applicant or future building o cupant atom or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.11, and Ibe Health and Safety
Code, Section 25532(a)? ''
Yes '�jb
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes )(No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 15505.25533 and 25534.1 understand tit if the bolding
does not currently have a ImanL khat It is my responsibility to notify the occupant of the
requ/ire�ments which mus t prior to issuance of a Certificate of Occupancy. /
42,
Owner or authorized agent - ` J Date_
Job Description
NEW GOLF MAINTENANCE BLDG W/ YARD, KIOSK, PARKING
LOT.CONSTRUCT STEVENS CREEK TRAIL TO MCCLELLAN
RD.
RENOVATE BLACKBERRY FARM PICNIC/RECREATION
Sq. Ft.
10000
APN Number Occupancy Type
35710005.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date / 7�
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.
Signature of Applicant
Date
All roof coverings to be Class'%" or better