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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
JOHN CASTELLO
PERMIT NOO 3 0 5 0 0 4 3
OWNER'S NAME:
10625 FLORA VISTA AVE.
PERMITlSsjj:De 2/ 2 0 0 3
�j/1
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of thc Business and Professions Code, and my license is
in and effect.
REFRAME &
REROOF
Licenseicense Class Lic. p
Date Contractor
ARCHITECT'S DECLARATION
I 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 rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
$ 21."ti on
(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
3 2A1-belfl 0
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
—FOUNDA d Inspections
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
Professions Code: The Contractor's License Law docs to an
and not apply owner of
10 2
- PIERS
property who builds or improves thereon, and who doessuch work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
103
— OF E R
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
104
- REBAR
sale')'
105
- ANCHOR BOLTS
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
10 6
SEWER
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
- & WATER
.
cerise Law docs not apply to an owner of property who builds or improves thereon, and .
202
- UNDERFLOOR PLUMBING
who contracts for such projects s`vtth antraclR.r(s) sed pursuant to the Contractor's
License Law.
205
- UNDERFLOOR INSULATION
✓
3 O 1
— ROUGH PLUMBING
I hereby, inn under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
3 02
— TUB & OR SHOWER
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303
- ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
❑ I have and will maintain Worker's Compensation insurance, as required by Section
3 05
FRAME
3700 of the Labor Code, for the performance of the work for which this permit is issued.
—
My Worker's Compensation Insurance carrier and Policy number are:
306
— HOLDOWNS
Carrier. Policy307
- INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
308
- SHEETROCK
ifthi}isfor®nehundreddollars($100)
(Thissectionncednotbecom mcdeperm
309
- EXTERIOR LATH
or less.)
310
- INTERIOR LATH
I certify that in the dorm ne f� agqrrk for w r it is issued, l shall not
o the orkcrs' Comns
employ any person
•.
313
- ROOF NAIL
Appl• nt .,�
NO C6E TO APP ICAPT: If, after making this Certificate of Exemption, you should
501
- FINAL ELECTRICAL ENERGY
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.
502
— F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
1 hereby affirm that there is a construction lending agency for the performance of
504
- FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
505
506
- FINAL ELECTRICAL
- GAS TEST
Lenders Address
1 certify that I have read this application and state that the above information is
507
- FINAL PLUMBING
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 theF
I NA MEC CAL
above-mentioned property for inspection purposes.
"Indemnify
4nq\
F I N
(We) agree ta-save; and keep harmless the City of Cupertino against
j liabilities, judgme(tis, costs and nses which may in any way accrue against said City
5
. ^\
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Re -roofs
Type of Roof
ign ore of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
ill the applicant or future building occupant store or handle hazardous material
as deft° d by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
25532(x)? ���///
Code, Section]Yes
All roofs shall be inspected prior to any roofing material being installed.
❑Yes o
If a roof is installed
without first obtaining an inspection, I agree to remove
Will the applicant or tutor building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes Nu
__
Ihavcma ehazardous (erialsrequit under Chapter 6.95ofthcCalifor-
nia Heal, S ty, odc,$ecd_ s 505,25533 t953 . derstandthatifthe building
'
docs not curt Ll ha e a ten % at it ism nsibilit n 'f the occupant of the
requiremen
-' Z
All roof coverings to be Class "B" or better
Owner oq/authori-rcd agent Date3