7040221CITY OF CUPERTINO
BUILDING DIVISION PER 1
BurLL11'6tbl"E RESCENT CT, LOT 1
a 3
PERMIT NO.
TBD — TO BE DETERMINED 07040221
OWNER'S NAME:PERMIT nUE BATE
KELLY GORDON DEVELOPMENT 06/28/2007
PHONE: SANTTARY N0. CONTROL NO.
ARCHITECT/ENGINEER:
o a LICENSED CONTRACTOR'S DECLARATION
U P 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
= y with Section and
of ecDivision 3 0(the Business and Prof �de, andmy license is
in full force and cf(xt.
License Class Lic. # -
F, ❑ Date
_ Contractor
w A CHITECCS DECLARATION
J
Z4< 1 understand my plans shall be used as public records
iV
LLo y Licensed Professional
OWNER -BUILDER DECLARATION
ag I hereby affirm that I am exempt from the Contractor's License Law for the
a 0 following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires tnc applicant for such permit to Glc a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
S (commencing with Section 70D0) of Division 3 a(lhe Business and Professions Codc) or
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 (5500),
❑ 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 forsale (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
own employees, provided that such improvements are not intended or offered for We. 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 contracting with licnsed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law docs nor apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contactor(s) licensed pursuant to the Contractors
License Law.
❑ I 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:
❑ I have and will maintain a Certificate ofConsent to self -insure for Worker's Compen-
stition, as provided for by Section 3700 of the Labor Codc, far the performance of the
work for which this permit is issued.
❑ I have and wi)l 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 Work ompensalion Ins u ce carrier and Policy nunter are: y i
Carrier.�Policy No.:
CERTIFICATEOFEX PTION f
FROM WORKERS'
COMPENSATION INSURANCE
(chis section recd not be completed if the permit is for uric hundred dollars (S 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 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 Labor Code, you must
2 forthwith comply with such provisions or this permit shall be deemed revoked.
OCONSTRUCTION LENDING AGENCY
�-+ I hereby affirm that there is a consuuedon lending agency for the performance of
Yy the work for which this permit is issued (Sec. 3097, Civ. C.)
17 Q Lenders Name
14 Lender's Address
::) 2
J O I certify that I have read this application and state that the above information is
r--+ correct. I agree to comply with all city and county ordinances and state laws relating to
U building construction, and hereby auehori7t repmes
rescativof this city to enter upon the
U 'hove-mlnuoned property for inspeccion purposes.
y a (We) agree to save, indemnify and keep harmless the City of Cupertino against
;y [n liabilities, judgments, costs and expenses which may in any way accrue against said City
J 2 in consequence of the granting of this permit,
toed by thCupertino Municipal Codc, Chapter 9.12, and the Health and Safety
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?
❑ Yes
I have mad the hazardous materials requirements uncierChapier 6.95 of the Califor-
nia Health & SafelyCode. Sections 25505, 25533 and 25534.1 understand that if the building
does no a tenant, that it is my responsibility to notify the occupant of the
reyuireme 'ch
__ �R1a2
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
CONSTRUC NEW SINGLE FAMILY RESIDENCE
ON LOT 1
Sq. Ft. Floor Area $889352 Valuation
3261709. OVN Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy 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 of Applicant
A
Date