07040212rY OF CUPERTINO
BUILDING DIVISION PERMIT
Bu1LTdd""bAKLEAF PL
OWNER'
PHONE:
ARCHMCT/ENGINEER:
Z LICENSED CONTRACTOR'S DECLARATION
0
F I hereby affirm that 1 am licensed under provisions of Chaptcr 9 (commencing
UW with Section 7000) of Division 3 of the Business and Professions Code, and my license is
a in full force and effect
License Cass ` � Lie. 0 ��
p
Date — 1 Contractor ��.�'—,r 9 W Az 05 �
ARCHITECI-S DECLARATION
'-� 1 understand my plans shall he used as public reenrds
U
N Licensed Professional
OWNER -BUILDER DECLARATION
M I hereby affirm that I am exempt from the Contractor's License Law for the
O following reason. (Section 703 1.5. Business and Professions Code: Any city or county
�i which requires a permit to construct, after, improve, demolish, or repair any structure
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
o(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
. m that he is exempt therefrom and the basis foi 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).
❑ 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 sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered forsale. 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.).
❑ I, as owner of the property, am exclusively contacting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Conu actors Li-
cense Law docs 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 exempt under Sec , B & P C for this reason
Owner Date
WORKER'S 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 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 Code, for the performance of the work for which this permit is issued
My Workers Compensation Intarrirl and Policy numbeyr are;
Carrier. ^ � 'l1/ fk 0 Policy No.: 5t
t m'TW
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 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 Worker's Compensation provisions of the tabor Code, you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
t--� 1 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.)
iz Lender's Name
Z Lender's Address
Q 1 certify that I have read this application and state that the above information is
'—'
correct. 1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction. and hereby authorise representatives of this city to enter upon the
W ahovc-mentioned property for inspection purposes.
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
fn liabilities, judgments, costs and expenses which may in any way accrue againstsaid City
Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
ALS DISCLOSURE
Will the ap�1' nt 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)?
❑ YesD( No
Will the applicant or future building occupant use equipment or devices which
emit ha-rardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ YesNu
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
docs not currently hale a tenant, that it is my responsibility to notify the occupant of the
reouiremcros of a Certificate of Occunatrcv. .
Owner or
.........:...... ... - PERMIT NO.
PATTY NG. 07010007
PERMIT ISSUE DATE
04/03/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
ADD 383' EXTEND FAMILYRM,ADD BEDROOM. REMODEL
400'
KITCHEN -ADD 135' KITCHEN/NOOK PERMIT #07040212.
Sq. Ft. Floor Area $122403 Valuation
32618055 Number Occupancy Type
Required Inspections
Issued by:
Re -roofs
Type of Roof
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 "B" or better