07040126BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
10421 SCENIC BLVD
OWNER'S NAME:
PHONE:
ARCHITECTIENGINEER:
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
mith Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and effect.
Licensc Class Lie.#
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, 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 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
(commencing with Section 7000) of Division 3 of the Business and Professions Code) 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 (S500).
❑ 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 (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 tale. 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
as owner of the properly, am exclusively contracting with licensed contractors to
onstrvct the project (Se 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not app to an owner of propeny who builds or improves thereon, and.
who contras for such ' s with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt , B& P C f this n
Owner Date / / G'
S CPMPENSATION DECLARATION
1 hereVed
nder penalty of perjury one of the following declarations
❑ 1 have andintain a Certificate of Consent to self -insure for WorkeesCompen-
sation, as pror by,"
y 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 Codc. 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 forone hundred dollars ($100)
or less.)
I certify that in the per ante of the work for hich 's permit is issued. I shall not
employ any person in y anner so as c je t}o}ftlf Workcrs' Compensation
Laws of VV ��
Applicant
NOTICE T If. to making this Certificate of Exemption, you should
become sub ect to o er's Compensation provisions of the Labor Code, you must
forthwith c mply i so h provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
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 authome representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(Wc) a e to save, indemnify and keep harmless the City of Cupertino against
liabilities, jud ens, toss and expenses which may in any way accrue against said City
in consequen of the granting of this permit.
t
HAZARDOUS MATERIALS DISCLOSURE
ll the applicant or future building occupant store or handle hazardous material
asV.,"tion
bythe Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
C 25532(a)?
❑Yes o
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 No
I have rcad theharardo smaterialsrequircr crs under Chapter 6.95oftheCalifor-
nialicalth&SafctyCodc, Sec Ions 505,25533 d 34.1ontic 'Gthc..huilding
does not currently have a tc nt, a 't is m r i1' nod' thc occupant of the
requirements which must of Occupancy.
TBD - TO BE DETERMINED
PERMIT NO.
07040126
PERMIT ISSUE DATE
07/11/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
ADDITION 2,570' 1ST FLR DINING, KITCHEN,
FAMILY,LIVING,LAUNDRY/GARAGE 552'-2ND FLR
MASTERSUITE,3 BEDROOMS,BATH & LAUNDRY. REMODEL
Ft. Floor Area
3 5 7 0 2 014 .1b16'sl Number
Issued by:
Re -roofs
Type of Roof
$750000
Required Inspections
Date
uation
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