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CITY OF CUP]ERTE
BUILDING DIVISION
BUILDING ADDRESS:
21860 ALCAZAR AVE
ARCHITECT/ENGINEER:
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PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license
is in full force and effect.
License Class Lic. N
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (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
th@t h4 is )icensed pursuant 16 the provisions of the Contractor's License Law (Chapter 9
(commencing with,Secuon 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
ofSection'7031.5 by applicxm for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the worn, and -me stikture 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.).
ts owner of the property, am exclusively contracting with licensed contractors to
o;M0the 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,
❑ 1 am excmpt ndcr Sec. - , B & P C for this reason
Owper
t J(t�f/ WORKER'S CO TI N DEC1L�ARA(T�ION
I hereby affirm under penalty of perjury on�f the follPwin-- tions:
❑ 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.
01 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 Workers Compensation Insurance carrier and Policy number are:
Carries ' - Policy No.: _
CERTIFICATION OF EXEMPTION FROM',WORKERS'
COMPENSATION INSURANCE
` (This section need not be completed if the permit is for one hundred dollars
(5100) or less.)
1 certify th in the performance of the work for which this permit is issued, I
shall not
of Exemption, you should
become subject to the Worker's Compansauon provisioft of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
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, Civ. C.)
Lender'sName''.
Lenders 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 representauvei of this city to enter upon
the above-mentioned property for inspection purposes.
(We) agree to savii"indemnify and keep harmless the City of Cupertino against
liabilities, judgments. costs gnd expenses which may in any way accrue against said
City inconsequence of thftlinting of this pc;ku : '
3WftP! - " 'Date -
HAZARDOUS MATERIAL DISCLOSUI,%'
' Wi)1 dee' applicam or future building occupant 'store or handle hazardous material
�s defined by the Cupertino Municipal C e, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?, ,
0 Yes, ' o
Will the applicant or future building occupant use equipment or devices which
emit hazardous sit contaminants as defined by the Bay Area Air Quality Management
District?
0 Yes jJdvo
'I have read the hh*dous materials requirements under Chapter C95 of the
California Heilth &*Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does as cu �tiy have a tenant, that it is my responsibility to notify the
occupa� et prior to issusmce of it Certificate of
CONTRACTOR
PERMIT Np.2 0 3 0 219
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PPLI"11 S�!j LTI 2 0 0 2
SANITARY NO. y / CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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NEW SINGLE FAM YD PLMNG.
LIVING SPACE 3867 SQ.FT.
GARAGE 438 SQ.FT.
Sq: Ft. Floor Area -
35
on
Occupancy
1 U 1 - r UU1vLrjl RV4hired Inspections
102 - PIERS
103 - UFER
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 - SHEET -ROCK
309 — EXTERIOR LATH
310 - -. INTERIOR LATH.
311 - SCRATCH COAT
313 - ROOF NAIL
501 - FINAL ELECTRICAL ENERGY
502 - FINAL PLUMBING ENERGX.
503 - FINAL MECHANICAL ENERGY
504 - FINAL BUILDING ENERGY'
505 - FINAL ELECTRICAL
506 - GAS; TEST
507 - FINAL PLUMBING
508 - FINAL MECHANICAL
509 - FINAL GRADE
510 N ING
Issued b�r1.4' z. , RKS Date
Re -roof O U%G - ccvvr r1 t 1 vvvvL lvt>.1 L
Type of 0 3 - ROOF BATTENS
aq - ROOF IN -PROGRESS
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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 rB" or better