02020063-DPCITY OF CUPERTINO
BUILDING DMSION PERMIT
BUILDING ADDRESS:,
20910 ELENDA DR
PHONE:
0 c0 Zo ARCHITECTIENGINEER:
AUL,
?ZLL)
nab
Z` LICENSED CONTRACTOR'S DECLARATION
Z = — { I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
rn F � i with Section 700D) of Division 3 of the Bu 'nys and Professions Code. and my license
,2 , is in full fo d effect Li .
F�(� O
ce r ¢ �Li¢¢nse Cla
a v Q(re Contra r
CHITECT'S DECL TI t
I understand my plans shall be used as public records
p O Licensed Professional
xF ` OWNER -BUILDER DECLARATION
= ro I hereby affirm that I am exempt from the Contractor's License Law for the
F' Z < following reason. (Section 70315, Business and Professions Code: Any. city or county
n< which requires a permit to construct. alter, improve, demolish. or repair any structure
to F m prior to its issuance. also -requires the applicant for such petit to file a signed statement
a 3 — that he is ficemied puisuani to the pfovisions of die Contractors License Law (Chapter 9
(commencing witli-Section 7M) 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 703 1.5 byany applicant�for a permit subjects the applicant to a civil penalty'
of not more than five hundred dollars ($500).
❑ 1, as owner of die property, ar 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 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
License 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
_ Contractor's License Law.
❑ I am exempt under Sec. , B & P C for this reason
- Owner Date
- WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations;
5� ❑ 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
performance of the work for which this permit is issued.
❑ 1 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. May Worker's
Worker s Compensation Insurance er and Policy number are:
erg/ / a'�e /tell j Polic 4,R �nl t
CERTIFICATION OP EXEAd� FROM WORKERS'
COMPENSATION INSURANCE -
(This section need not be completed if the permit is for one hundred dollars
($100) or less.)
G 1 -certify That in the performance of the work far 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 TOAPPLICANT: If, after making this Certificate of Exemption, you should
Z become subject to the Worker's Compensation provisions of the Labor Code, you must
ZO : forthwith comply with such provisions or this permit shall be deemed revoked.
N rte. CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance
of the work for which this permit is issued (Sec. 3097, Ci`. C.)
. A fender's Name' -
Lender's`Address
V C I certify that I have read this application and slate that the above information is
correct. I agree to comply with all city And county ordinances and state laws relating
(, to building conswction, and hereby authorize representatives of this city to enter upon
>� the above-mentioned property for inspection purposes.., .
[.i ':r (NVe) agree to save, indemnify and keep harmless the City of Cupertino against
Uto
liabilities, judgments, costs and expenses which may in any way accrue against said
V rZ.i City in consequence of the granting of this permit_
APPLICA2Na U_' �STANDS AND WILL COMPLY WITH ALL \ON-P„QLNT
chtaarFbEM /.tnoar:�--i __ r r� �L _,erg
HAZARbO' US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertinq Municipal Code, Chapter 9.12. and the Health and Safety
Code. Section 25532(a)7 - - —
❑ Yes,No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District?
11 Yes `ICN.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505.25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
iccupant of th
- Date
CONTRACTOR INFORMATION:
IO
CTM CONSTRUCTION
2308 WALNUT GROVE AVE
(408) 554-0198
ADDITION
3 §9A fiP2r.40a
10
iRMIT NO.
02020063
PPLIC TIONS B DATE
02%19 2002
\NITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
U E__I L . 1 �]
Job Description
TION
$125000
Valuation
103 - UFER Required Inspections
104 - REBAR
105 - ANCHOR BOLTS
106 - SEWER & WATER
202 = UNDERFLOOR PLUMBING
203 - UNDERFLOOR MECHANICAL
204 - UNDERFLOOR FRAME -
205 - UNDERFLOOR INSULATION
301 - ROUGH PLUMBING
302 - TUB & OR SHOWER
303 - ROUGH MECHANICAL
304 - ROUGH ELECTRICAL
305 - FRAME
306 - HOLDOWNS
307 - INSULATION
308 - SHEETROCK
309 - EXTERIOR LATH
310. - 'INTERIOR LATH
311 - SCRATCH COAT
313 --ROOF NAIL
501 - FINAL ELECTRICAL'ENERGY
502 - FINAL PLUMBING ENERGY
503 - FINAL MECHANICAL ENERGY
504 - FINAL BUILDING ENERGX,
505 - FINAL ELECTRICAL
506 - GAS TEST
507 - FINAL PLUMBING
508 - FINAL MECHANICAL
509 - FINAL GRADE
510 - FINAL PLANNING
514 - FINAL PUBLIC WORKS
Issued by: Date
Re -roofs
Type of Roof
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. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant Date
All roof coverings to be Class `B" or better
OFFICE