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CITY OF CUPERTI NO
BUILDING DIVISION
BUILDING ADDRESS:
PHONE:
ARCHITECT/ENGINEER:
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. #
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
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
that lid; is licensed pursuant id fieQrevisions of the Contractor's License Law (Chapter 9
(cmtunepcing,with Section 7000) o(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 7031.5 by any applicant for a permit subjects the applicant to a civil penalty
of not more than five hundred dollars (5500).
❑ I, as owner of the property, or 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 Bile. 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.).
Aas owner of the property, am exclusively contracting with licensed contractors to
struct 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
Contractors License Law.
❑ I am exempt under Sec. . B & P C for this reason
Owper %'� /0 Z
, L WORKER'S CO PENSAQ0 ECLARATION
J� I hereby affirm under penalty of perjury yone of the following declarations:
❑ 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.
❑ 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
issued. My Workers Compensation Insurance carrier and Policy number are:
Carver. t 'Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE • '
(Chis section need not be completed if the permit is for one hundred dollars
($100) or less.)
I certify that in the
ate of Exemption, you should
Xlo e 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.
CONSTRUCTION LENDING AGENCY
1 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's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. 1 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
the above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accrue against said
City in consequence of the granting of this permit.
APWICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(x)'
0 Yes'No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes No
1 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 curtently have a tenant, that it is my responsibility to notify the
occupant of the requirements which must be met prior to issuance of a Certificate of
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CONTRACTOR
11631 UPLAND WAY
TENNIS COURT
PERMIT NO.
02060 30
APPLICATION SUB DATE
06/20/2002
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Job Description
$30000
Sg. Ft. Floor Area,, .:, Y , , •, : ,I Valuation
3 6.60.3 0''11 .'0'0 '% {
101 - FOUNDATION
1 V ` - r 1 rail .7 Required Inspections
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
3.07...-. 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 ENERGY.
505 - FINAL ELECTRICAL
506 - GAS TEST
507 - FINAL PLUMBING -
508 - FINAL MECHANICAL
509 - FINAL GRADE
510 - FINAL PLANNING
514 r F NALy9�� WORKS
Issued by:
Re -roofs
Type of Roof
0
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without fust 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 tB" or better
OFFICE