08110075L A yr %, Urrx\i Al Iv
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
21979 SAN FERNANDO A
OWNER'S NAME:
DTR
u O p LICENSED CONTRACTOR'S DECLARATION
V (: I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
z H with Section 70W) of Division 3 of the Business and Professions Code, and my license is
y in full force and a fea
License Class Lic, N
F, a Date Contractor
t; j ARCHITECTS DECLARATION
oG e 1 understand my plans shall he used as public records
7yU
iO y Licensed Professional
n y OWNER -BUILDER DECLARATION
a 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
is Q O following reason. (Section 7031.5, Business and Professions Code: Any city or county
,c w li which requires a permit to CmtarnCL alter, improve, demolish. or repair any structure
y Z y prior m its issuance, also requires the applicant for such permit to file a signed statement
T G that be is licensed pursuant to the provisionsorthe Contractor's License Law (Chapter 9
(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 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 1, 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 forsaie (Sec. 7044, Business
and Professions Code: The ContiWor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own 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 contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
cense 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.
❑ 1 am exgmpt under Sec
Date I I
WORKER'S CO ENSATIO ECLARATION
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 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF UEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor one hundred dollars ($100)
or less.)
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' Compensadon
Laws of Cali fo ice. Date
Applicant°''
NOTICE TO APPLICANT: If, after making this Ch4t3catc of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
ZCONSTRUCTION LENDING AGENCY
(—t ►�-+ I hereby affirm that there is a construction lending agency for the performance of
Mthe work for which this permit is issued (Sec. 3097, Civ. C.)
Q Lender's Name
Q z Lender's Address
U Q I certify that I have read this application and state that the above information is
L4 h"t correct. I agree to comply with all city and county ordinances and state laws relating to
Q V building construction, and hereby authorize representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
r j liabilities, judgments, costs and expenses which may in any way accrue against said City
lJ Z in consequence of the granting of this permiL
►'t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
50
Date
HAZARDOUS MA ALS DISCLOSURE
Will the applicant or future building occupant state or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes *No
Will the applicant or future building occupant use equipment or devices which
MR. hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
El Yes Ola
I have read the hazardous materials requirements underChapter 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
rcq[uj�ejmcrtts " which mu met prior to issuance of a Certificate of Occupancy.
f ts'A. nn a,,,, _ _ ii I Zo A 0,
Owner or authorized agent (- Date
408)279-2277
PERMIT NO.
08110075
PMU,drr ISSUE DATE
A CONTROL NO.
BUILDING PERMrr INFO
BLDG ELECT PLUMB
Job Description
TEMPORARY PERMIT FOR FOLF MAINTENANCE $LD***ONLY
PERMIT GOOD THRU 12/20/2008
Sq.
35710005.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Type
Date
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