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CITY OF CUPERTINO`'
DIVISION
CONTRA,CT'OR I1Fb
BUILDING Irr
BUILDING ADDRESS:
PERMIT NO.
10210 STERN AVE
HENRY LO
02060151
PPLIC 06r2UB D
APPLICATION/24
4 %2 O O 2
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
_I— u L= r�
LICENSED CONTRACTOR'S DECLARATION
e Cn tTOn
hereby affirm that ! am licensed under provisions of Chapter 9 (commencing
NEW SINGLE
,I4b
FAM I L 1' DW's E nLING
with Section 7000) of Division 3 of the Business and Professions Code, and my license
is in full force and effect.
LIVING
SPACE 3249 S Q. F T.
License Class Lic.ff
Date Contractor
GARAGE
674 SQ . FT .
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I 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. atter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
.. ... ... _ .......... . ..
-Sq. F,t.,
. •C.
Area.
ODr ,. t, ! r • -
't '
$ 4 0 0 0 ®luation
that he is licensed pursuant td d+ provisions of the Contractors License Law (Chapter 9
(commencing with Section 700+ of Division 3 of the Business and Professions Code)
or that he Is exempt therefrofi *d the basis for the alleged exemption. Any violation
'
of Section 7031.5 by any upplicaht for a permit -subjects the applicant to a civil penalty -
of not more than five hundred dollars ($500).
3 7 5 MN ftIPb(9
Occupancy Type
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and thcstructure is not intended or offered'for We (Sec. -7044,
Business'and'Professions Code: The Contractor's License Law does not apply to an
101 —
FOt.-i�IDAT I %huired Inspections'
owner of property Who builds or improves thereon, and who does such work himself
102 —
PIERS
or thare rough his own employees. provided that such improvements anot intended or
offered for sale. If, however, the building of improvement is sold within one year of
10 3 —
UFER .
completion, the owner -builder will have the burden of proving that he did not build or
improve for purpose of sale.).
104 —
REBAR
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
105 -
ANCHOR - B OL TS" -
rac
construct the project (Sec. 7044, Business and Professions Code:) The Conttor's
10 6 -
SEWER & WATER '
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
202 -
UNDERFLOOR -P-LUMBING
exam ,B&P for this reason
tractor'
NLR AT10N
205 —
UNDERFLOOR INSULATION
1 hereenalty of perjury one of the fonowing d«lamdons:
301 —
ROUGH PLUMBING
❑ I have And will maintain a'Certificate of Consent to self -insure for Workers
302 —
TUB & OR SHOWER
Compensation, as provided for by section 3700 of the Labor Code, for the
303 -
ROUGH MECHANICAL
performance of the work for which this permit is issued.
304 -
ROUGH ELECTRICAL
❑ 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
3 05 —
FRAME
issued. My Worker's Compensation Insurance carrier and Policy number are:
306 —
HOLDOWNS
Cartier. .licy No.:
CERTIFICATION OF EXoEMPTION FROM WORKERS'
307 —
INSULATION
COMPENSATION INSURANCE
- — 308..
SHE'ETROCK- -"
(This section need riot he completed if the permit is for one hundred dollars
3 09 -
EXTERIOR LATH
� ($100) or less.)
310 -
"INTERIOR LATH
7 I certify that in the perfomianc f the work for which tVs permit is issued, I
Workers'
311 —
SCRATCH COAT
shall not employ any rson in nee s to a oq a bject to the
Compensation
Jpvjm�oZns
rh
501 -
FINAL ELECTRICAL ENERGY
ubl o :nsation provisions you
forthwith comply with such or this permit shall be deemed revoked.
502 —
FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 -
FINAL MECHANICAL ENERGY
I hereby affirm that there is a construction lending agency for the performance
504 -
FINAL BUILDING ENERGY
of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name " " -
505 -
FINAL ELECTRICAL
Lender's Address
506
GAS TEST
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
5 -
I NAL PLUMBING
to building construction, and hereby authorize representatives of this city to enter upon
5 8 -
I NAL I CAL
the above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
50 -
I NAL
liabilities, judgments, costs and expenses which may in any way accrue against said
City in this
510 —
F
c°nsequ ce of the granting of permit.
ST
APPLICAN r DERSTA\D.S YD WILL COb[PLY W HALL 'ON- L
Issued •
Date
SO IONS.
-
Re-ro
`S' nature ofp Date
HAz OUS MATERIALS DISC
RO BATTENS
Wil the applicant future building'occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Type of
yp —
R F IN—PROGRESS
Code, Section 25532(a)7 .
❑YeS"
All.roofs shall be inspected prior.to_any.,roofing material being installed.
Will 'he applicant or futq�b,ilding occupant use equipment or devices whichWill the applicant or fu 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
❑Y`sl°
all non -point source
regulations.
I have read the hazard s materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. I understand that
if the building does not currently have a tenant, that it is my responsibility to notify
occupant of the re irements w ' h must be met prior to issuan of a Cemfic of
- — —
Occupancy. 0
Signature of Applicant Date
Owner or autho' a gen l�� Date
All roof coverings to be Class `B" or better