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CITY OF CUPERTINO
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CONTRACTOR &0bi�4
BUILDING DIVISION PERP
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BUILDING ADDRESS:
PERMIT NO.
10225 COLBY AV
02090049
APPLICAT OIQN,Sj,1B9n002
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PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
�JT ba �D�S ption
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
ADD
499 S Q FT / K 1�lUll�
with Section 7000) of Division 3 of the Business and Professions Code, and my license
. .
is in full force and effect.
License Class Lic. #
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
$56088
which requires a permit to construct, alter, improve, demolish, or repair any ,uucture
prior to its issuance, also requires the applicant for such permit to file a signed statement
3 .1 ft�0 �9 ea
Valuation
that ha i� 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)
t •. ,
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 dof�ars ($500).
101 A-PNIT'41ErAT ION
Occupancy Type
0 I, as owner of the property, or my employees with wages as their sole compensation,
102
- PIERS
-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
103
— UFER Required Inspections
owner of property Who builds or improves thereon, and who does such work himself
104
- REBAR
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
10 5
— ANCHOR BOLTS
completion, the owner -builder will have the burden of proving that he did not build or
10 6
SEWER & WATER
improve for purpose of sale.)
—
WI, as owner of the property, am exclusively contracting with licensed contractors to
202
- UNDERFLOOR PLUMBING
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's
203
— UNDERFLOOR MECHANICAL
License Law does not apply to an owner of property who builds or improves thereon,
and who contracts for such projects with a conuactor(s) licensed pursuant to the
204
— UNDERFLOOR FRAME
01ameContractor's License Law.
❑ I ante pt�tder Sec. , B & P C for this reason
205
— UNDERFLOOR INSULATION
' DECLARATION
302
— TUB & OR SHOWER
1 hereby affirm under penalty of perjury one of the following declarations:
303
— ROUGH MECHANICAL
0 1 have and will maintain a Certificate of Consent to self -insure for Worker's
304
— ROUGH ELECTRICAL
Compensation, its provided for by Section 3700 of the Labor Cade, for the
305
— FRAME
performance of the work for which this permit is issued.
306
— HOLDOWNS
0 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
307
— INSULATION
issued. My Worker's Compensation Insurance carrier and Policy number are:
308
— SHEETROCK
Carrier: Policy No.:
309
` t EXTM I OR � LATH
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
310
— INTERI.OR LATH--- -
(This section need not be completed if the permit is for one hundred dollars'
311
— SCRATCH COAT
($100) or less.)
313
— ROOF NAIL
I certify that in the pe Forman of the work for which this permit is issued, I
shall not an on in n
6AlO Become subject to the Workers'
5 01
— FINAL ELECTRICAL ENERGY
atant>ef
Compensationlay
f ANT: If 'after making this Certificate of Exemption, you should
503
— F I NAL ME CHAN I CAL ENERGY
be subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
504
— F I NAL BUILDING ENERGY
CONSTRUCTION LENDING AGENCY
505
— FINAL ELECTRICAL
I hereby affirm that there is a construction lending agency for the performance
506
- GAS TEST
of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
507
- F I NAL PLUMBING
Lender's Address
508
FINAL MECHANICAL
1 certify that 1 have read this application and state that the above information is
5
I NAL GRADE
correct. I agree to comply with all city and county ordinances and state laws relating
— -
to building construction, and hereby authorize representatives of this city to enter upon
5 0
- I NAL P NG
the above-mentioned property for inspection purposes -
(We) agree to save, indemnify and keep harmless the City of Cupertino against
51
_ I NAL B R S
liabilities, judgments, costs and expenses which, may in any way accrue against said
City in consequence of the of this permit.
COJ(PLY WITH : N -POINT
Issued by•
Date
SOP
01 a2
S' a re of ApplicaoNContraFtor ate
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
Type of Roof
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)^
0Yes XNo
All roofs shall
be inspected prior to any roofing.. material being installed.
Will the applicant or future building occupant use equipment or devices which
If a roof is installed
without first obtaining an inspection, I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
all new materials for inspection. Applicant understands and will comply with
❑Yes ZINO
all non -point source regulations.
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
occupant of l"quirements which must he met prior to issuance of a Certificate of
Occupy
0`_
Signature of
Applicant Date
All roof coverings to be Class `B" or better
ner or authorized agent I Date —
OFFICE