07050068CITY OF CUPERTINU I�p,�
BUILDING DIVISION PE,A AHT
BUILDUIGADDRESS:
OWNER'S NAME:
PHONE:
GEORGE ADZICH
21850 G
PERMIT NO.
07050068
PERMIT LSSUE DATE
CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
7_
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
,itis Section 7") of Division 3 of the Business and Professions Codc, and my license is
I full force and effect.
.icensc Class Lic. tf
talc Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
-icenscd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
ollowing reason. (Section 7031.5, Business and Professions Code: Any city or county
Mich requires a permit to construct, alter, improve, demolish, nr repair any structure
trior to its issuance, also requires the applicant forsuch permit to Glc a signed statement
hat he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
hat he is exempt therefrom and the basis for the alleged exemption- Any violation of
lection 7031 S by any applicant for a permit subjects the applicant to a civil penalty of
rot more than five hundred dollars
] L 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 rale (Sec. 7044, Business
and Professions Code: The Contractor'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
awn 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.),
:3 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors 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 Contractors
License Law.
❑ I amexem t under Sec . B & P C for this reason
Owner Date T t o
CGIMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compe t-
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 Worker's Compensation Insurance carrier and Policy number are:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
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 maanncrss L3 o be glsrc subject to the Workcrs' Compensation
Laws of Calijprrtia. Date T'
Applicant
NOTICE TO APP , ANT: 1 , after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, 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 fug which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
I certify that 1 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
building construction. and hereby authorim representatives of this city to enter upon the
ahove-mentioned property for inspecUon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLI ANT UNDEAST NDS AND WILL COMPLY WITH ALL NON -POINT
.
Signature of Apli Co tract Date
HA7ARD0 IS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haurdous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the HcalEh and Safely
Code, Section 25532(a)? ���[[[
❑ Yes No
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?
E] Yes
No
1 have read the hamrd us materials requirements underChapicr 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant. that it is my responsibility m notify the nttrpat of Elie
issuance of a Certificate of foccupanty.
Job Description
SFDWL 2 STORY -LIVING 3,948', PATIO 947', GARAGE
812'.
Sq, Ft. Floor Area
35716019 . Number
Issued by:
Re -roofs
Type of Roof
Valuation
$929622
Occupancy T
Required Inspections
Date S-1 ")-
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