03090012 CITY OF COPEWFINO
BUILDING DIVISION PERMITCQNTRACTORlkINFORMATION
BUILDING ADDRESS: PERMIT Nf03090012
10221 HTT.T.CREST RD
O NERSNAME: PERMIT ISSUE DATE
11/19/2003
VIIIIINE: SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
±00 LICENSED CONTRACTOR'S DECLARATION
in1 hemby,from that 1 am licensed dodo provision or Chapter 9 aommeneing - Job Description
with llforc ande)ec Division JOf NC Business aM Profcsxinns Code,and myliccnu is ��N/ `LED
±�„ mmumrmanderaet ADD 1771 SQ. FT. (2 STO
sE2g License Class Lie.11
CF, Date uto
Cunacr
sy ARCHITECTS DECLARATION
4 y< 1 understand my pI.n..h.11 he died as Public records
s0ti
Licensed Pndcssicnal
DEC .�. 2004
S OWNERAUILD,f DECLARATION
Cmil ON
`�<Y 1 areby affirm Nat 1 em esempt from the Cmions C s License law fur the
00 following mason.(Section)n]L3.Business and professions Code:Any city or county
5$ which requires a Permit to construct,alter,improve,demolish,or repair any structure R1 11 DINrw75000
_Zaprior to its issuance.also requires the applicant for such Perm!t to file a signed statement
Nat he is licensed pursuanuo the provisions of the Consranur's License law(ChapterY Sq. F[. Floor Area Va uatlon
FIs-$ (Commencing with Section 7")of Division J of the B usincss and Pmfexsions Cook)or
40 that he is exempt tarefrom and the basis for the alleged cacmphon.Any violation of
Section)BJ 1.5 by any applicant for a permit subjects he applicant to a civil Penalty of e Occupancy Type
not more Nan five hundred dollars(SWB).
❑1.as,owmer of the pmpeny,or my employees wish wages u fair into compensation,
will do the work.and Ne structure is not intended or offered for sale(See.]Baa,Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q P
property who builds or improves thereon,and who does such work himself or through his
own employees,provided Nat such impruwmem s are not intended or offered for sale.If.
however,the building or impournment is sold within one)ear of completion,Ne Owner
builder will hale the bund,.of proving Nat he did not build of improve for purpose of
ale.).
1,u r of the pm,xmt.am exclusively contracting with licensed contractors to
co trees theproject(Sec.7014.Business and Professions Cade)The Contractor's Li.
cents law docs not apply to an owner of property who builds or improves tareon,and,
who contracts for such pmjecu with a conmactm(s)licensed pursuant Ne Contractors
Lice se Law.
❑I am exempt under Sec. .B&P C for this nation
ry:
Dw• r -
TION
I hereby affirm under Penally of Perjury one Of the following declaration:
I haw and will maintain a C,nifcau of COnxent m selGimum for Workers Compcm
salion.as provided(or by Smion J)BO of the Lathan Cotic,for Ne perfmmanCe of the
work for which this permit is issued.
1 have and will maintain Worker's Competunlnn Insurance,ae required by Sectio
37M of the labor Code.for the performance or the work for which this permit is Issued.
'
My Worker's Cnmpe.xation houninee carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF MEM PTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section nccd not a co n,dered fine permit is rmit a hundred dultars($IMI
Its..)
1 certify Nat in the purformenec or the work for which his Permit is issued.I shall not
employ any person in any manrerso a In aeome subject o to Workeot Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worceh Compensation previsions of she IaMu Code,you must
7Z foMwith Comply with such provisions or this Permit shall be iccmcdrevoked.
z O CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency lot the Performance of
iI4> she work fur which this permit is issued(Sce.3097,Clv.C.)
(Ll Q Lcndcrs Namc
= z Lender's Address
U O I certify that 1 have read this application and stem that the shout information is
U. (r" Carmel.I agree to comply with all city and county ordinances and stave laws relating to
0U building construction.and hereby suthoire mprescnmives of Nis city to enter upon the
�a gave-mentioned property for iaspecdon purpoi
(We)agree m save,indemnify and keep harmless Ne City of Cupertino against
Hy liabilities.judgments.coxes and,,penes which may in any way a,.0 against said City 1h(l
UZ in consequence of the granting u(this perm it. G
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOUR REGULAT NS. II
Re-roofs
gorrom.7 ADPlicaCOData
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant of(at.building occupant it..Or handle harandous mau is!
as defincd by the Cuperuma Municipal Code.Chapter 9.12,and to Health and Sarety
Code.section 255]20)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes `P No
will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
...nit haxaPonux air contaminants u defincd by the Bay Arca Air Quality Management all new materials for inspection.
DistricR
Fl Yes `�Nu
I have mad Ne hmanlrus matenals mquiremems under Chapter 6.95 of the Califnr
nia Health&Safe,,Cud,.Sane.255115,25533 and 23574.I understand Nat if the building
does not cumently have a tenant,that it is my responsibility In notify to ncupont of the
muircmcnu r' stbc hr=1 us.
I �1�1d1 All roof coverings to be Class•'B"or better
Owner or submited agent Dam
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10221 HILLCREST RD
CONTRACTOR: JOE DONOVAN
PERMIT NO: 03090012
CONSTRUCTION INC
OWNER'S NAME:
SAN JOSE, CA 95120
PHONE NO: (408)997-8140
❑ LICENSED CONTRACTOR'S DECLARATION
i� r T`
BUILDING PERMIT INTO: BLDG ELECT PLUMB
License Class Lic.#
r r r
MECII RESIDENTIAL COMMERCIAL
Contractor Date
JOB DESCRIPTION: ADD 1771 SQ.iT.(2 STORY)
REVISION -404010034404020009
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
Sq. Ft Floor Area:
Valuation: $275000
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
APN Number: 32615009.00
Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
correct. 1 agree to comply with all city and county ordinances and state laws relating
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by. Date:
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
RE -ROOFS:
Signature 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.
71OWNER-BUILDERDECLARATION
Signature of Applicant: Date:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
ALL ROOF COVERINGS TO BE CLASS "A" OR BE'VI'ER
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 for sale (See.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will
1 hereby affirm under penalty of perjury one of the following three
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
Health & Safety Code, Section 25532(a) should I store or handle hazardous
I have and will maintain a Certificate of Consent to self -insure for Worker's
material. Additionally, should 1 use equipment or devices which emit hazardous
Compensation. as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District 1
performance of the work for which this permit is issued,
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorized agent: Date:
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 Worker's
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRi:CTION .LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby aflirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (See 3097, Civ C.)
Lender's Name
APPLICANT CERTIFICATION
Lender's Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
9.18,
Signature Date
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