06090126BUILDING DIVISION
DE ANZA CIR
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER:
1-04 p LICENSED CONTRACTOR'S DECLARATION
v r"- I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
' ¢ ° in full farce and effect.
j v=Ni ? License Class Lic. p
e,ea Date Contractor
ARCHITECTS DECLARATION
i < f understand my plans shall be used as public records
>yU
Q y Licensed Professional
-y OWNER -BUILDER DECLARATION
a g I hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason. (Section 703 1.5, Business and Professions Code: Any city or wonty
Q 9 which requires a permit to construct, alter, improve, demolish, or repair any structure
z prior to its issuance, also requires the applicant forsuch permit to file a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
:2
� [-- m (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 penally of
not more than five hundred dollars ($500).
1711, 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 sale (Sec. 7044, Business
and Professions Code: The Contractors 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 propose 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 exe, ptAnder Sec , B & P C for this reason
Owner
COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure far WorkeesCompen-
sation, 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, 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.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100)
or Icss)
I certify that in the performance of the work for which Nis permit is issued. I shall not
employ any person in any m5p as tome subject to the Workers' Compensation
Laws of Califar ' —
Applicant
NOTICE T APPLICANT: If a ter making this Certificate of Exemption, you should
become subject to the Worke 's Compensation provisions of the labor Code, you must
.J 0 forthwith comply with such provisions or this permit shall be deemed revoked;
z' t-� CONSTRUCTION LENDING AGENCY
..�
1 hereby affirm that there is a construction lending agency for the performance of
C4 > the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lenders Name
Z Lender's Address
U 0 I certify that 1 have read this application and state that the above information is
Ly F correct. I agree to comply with all city and county ordinances and state laws relating to
0 U building construction. and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rF.t C/1 liabilities, judgments, costs and expenses which may in any way accrue against said City
U 2 in consequence of the granting of this permit.
APPLICANT UNDERSTAN AND WILL COMPLY WITH ALL NON -POINT
SOURCE
Signature of Applicant/Coritraclor Date
HAt2ARDOUS MATERIALS DISCLOSURE
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 25532(a)7 �j
[:]Yes leo
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 fi N"o
I havc read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safcty Code, Sections 25505.25533 and 25534. 1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of die
mquircme s *h must be mel prior to issuance of a Certificate of Occupancy.
9, -7_ rX)17
0J ncr or authorized agent Date
MARSHALL MAPLE
22285 S DE ANZA C
PERMIT NO.
06090126
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
ADDITION: 495', MINOR REMODELING TO AREAS WHERE
THE ADDITIONAL SQUARE FOOTAGE WILL BE, ADDITION
IS
TO THE MASTER BEDROOM, FAMILY ROOM & GUEST
BEDROOM
Sq. Ft. Floor
35602030:
Issued by:
Re -roofs
Type of Roof
$106113
Required Inspections
Date
Valuation
pancy Type
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 cf Applicant Date
All roof coverings to be Class "B" or better