06080263,Y OF CUPERTI
BUILDING DIVISION
BUILDING ADDRESS:
10554 APRICOT CT
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER:
Z LICENSED CONTRACTOR'S DECLARATION
;Z
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
LQ with Section 7000) of Division 3 of the Business and Professions Code, and my license is
c- in full force and effect.
License Class Lic. #
i0 Dale Contractor
.cu a ARCHITECTS DECLARATION
--t I understand my plans shall he used as public records
is
V
F- Licensed Prnfessional
A
OWNER -BUILDER DECLARATION
L I hereby affirm that I am exempt from the Contractor's License Law for the
OC following reason. (Section 7031.5, Business and Professions Code: Any city or county
li which requires a permit to construct, alter, 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 Contractors License Law (Chapter 9
- m (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 ($500).
❑ 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 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 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law dors 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-.. - Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to sel(-insure for Worker's Compen-
sairon, as provided for by Seetion 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 Code, for the performance of the work for which this permit is issued.
My Wo�wlsI�Coojnpen�pon Insurance carrier and Policy numb
Carder. _,4i ft-� (.� ii Policy No.: / 1
CERTIFICATE OF EXEMPTION FROM WORTCERS'
COMPENSATION I14SURANCE
(This section need not be completed if the permit is for one hundred dollars (5100)
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'sCompensation provisions of the Labor Code, you must
Oforthwith comply with such 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 (See. 3097, Civ. C.)
7 A Lendcr's Name
Z Lender's Address
0 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 rclating to
Jbuilding construction. and hereby authorize representatives of this city to enter upon the
y W above-mentioned property for inspection purposes.
y CL (We) agree to save, indemnify and keep harmless the City of Cupertino against
y c�P2 liabilities, judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
APPLICAN7 UNDERST��°°AA��°°��jj��QQQQQQS AND WILL COMPLY WITH ALL NON -POINT
SOURCE
% DateV
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant 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)?
0 Yes l�(No
Will the applicant or flutture building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District?
❑Yes No
1 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
does not ctently have a lepant, that it is my responsibility to notify the occupant of the
requirem issuance of a Certificate of Occupancy.
Date
PERMIT NO.
TBD - TO BE DETERMINED 06080263
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB MECH
Job Description
REMODEL -KITCHEN, FAMILY RM,DINING RM,ENTRY
ADDITION OF NEW COVERED ENTRY PORCH
NO SANITARY REQUIREMENTS 9/7/6
Sq. Ft. Floor Area
316 3 014 8APN
u u Number
Issued by:
Re -roofs
Type of Roof
$50000
Required Inspections
Valuation
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 Date
All roof coverings to be Class "B" or better