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CITY OF CUPERTINO y - ;:
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BUILDING DIVISION PLRMIT
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BUILDING ADDRESS:
PERMr"O.0 6 0 7 0 0 5 4
10371 PRUNE TREE LA
ClAiNER'
2006
SANITARY NO. CONTROL NO.
ARCH ITECT/ENGINEER:
BU(LDINO PERMrriNfO
HLl7 E PLUME
LICENSED CONTRACtDR'5 DECLARATION
Job Description
I hereby tf0nn that 1 am Hennaed under provisions of Chapter 9 (commencing
nhullfamoron7tdaffecD{vl+lonJafthe Husinessand ProfeuluneCode, mdmylicense ie
ADDITION-5621 LIVING/DINING ROOM -REMODEL ENTIRE
LlccnDo to sc Class lWWr
HOUSE 1, 8 7 6 1 - REROOF ENTIRE HOUSE.
ARCHRECTS DECL.ARA71ON
I understand my plans shall he used as public rocords
Licensed Prufcasionsl
OWNER -BUILDER DECLARATION
l hmcby affirm that 1 am exempt from ttc Contractors License Law for the
following reason. (Section 7031.5, Business and Profcsxionu Coda: Any city or county
which requires a permit to construct, alter, Improve, demolish, nr mpolr any structure
prior to its Issuance, also requires the applicant for such perroit W file a signed statement
Contractor's IJcensa Law (Chapter 9
Sq, Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
4 8 2
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
$ 3 0 9
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031J by any applicant for a permit subjects the applicant to a civil penalty of
not more (ban five bundred dollars (g50
t] 1, as owocr of the property, or my employees with wages at their sole compensation,,
,f
Required Ins ections
q p
will dothcwork,andthestructure13notln(endedoroffemdforWe(See,7044,Business
and Professions Code: The Contractor's Liccriso Law does not apply to an owner of
property who builds or improves thereon, and who does such work himseir ar through his
own employees, provided that such Improvements are not intended or offered for We. if,
however, the building or Improvement is told within one year of completion, tto owner.
builder wIB have the burden of proving that he did flat build Or improve for purpose of
I, u owner of the property, am exeluavdy eontracting with lcensed contractors id
Constnaet the project (Sec. 71344, Husin= and Professions Code:) The Coutrsctofs U.
Cann Law does not apply to an owner of property who Wilda or Improves thereon, and ,
who contracts for such projects with a contraaoKs) licensed pursuant to the Contractors
Llctoso Law.
❑ 1 am exempt under See. H &
penilty of perjury one of the following tltxluatiass:
O 1 haw and will maintain a Certificate of Censcnt to self-iasum for Wurket's Compen-
sation, as provided far by Sedan 37W of the Labor Code. for the performance of the
work for which this permit is Issued,
❑ 1 have and will maintain Workers Compenssdoo Imsonnce, is required by Section
3700 of (he Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number ate:
Carrier: Policy No.:
CERTIFICATE OP E EMPTION P tOM WORKERS'
COMPPNSATiON INSURANCE
"
(This section reed not bo completed ittbe permit is for Ono hundred dollars ($100)
or leis.)
I Certify that in the performance or the work for which this permit Is Issued, I shell not
employ any person in any mum 3>;bbaComcfubjecttatheWorkers'ComNmA0on
Laws of California Date r.._.. o /
the Workers Compensation provisions of the Labor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked.
1
CONSTRUCTION LENDiNO AGENCY
i i hereby affirm that thoro is A construction lending agcrcy for the performance of
the work for which this permil Is issued (See, 3097, Civ. C.)
Lendoes Name -- --
Lenders Address
i eerttfy that I have read this application and state [hit the show informatiun Is
t correct. I agree (o comply with all city and county ordinances and ante laws relating to
" WI$dingcgnstrvetion, and hereby authorim mpreunladwsOf this city to enterupon the
for inspection
? above-mcntiuned property purposes.
(Wa) agree to save, indemnify ►nd keep harmless the City of Cup etlno against
j 11wild- jtdgments,costs and expenses which may In any way accrue against said City
' In consequence of the granting of this permit
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT
Issued by: Date 6
SOURCE REGULATIONS,
w rf3e/L b
AnYl "
Signature of Appitcant/ConimWr Date
HAZARDOUS MATERIALS DISCLOSURE
'Mil the appllcant or future building occupant start of handle hazardous material
as deRned by the Cupertino Municipal Code, Chapter 9.17, and the Health and Safety
Section2553zcg7
fyNa
All roofs shall be inspected prior to any roofing material being installed.
0Ycs
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building occupant use equipment or device which
emit hamldnttt air contamintnts as dcBncd by the Bay Area Air Quality Management
all new materials for inspection.
OislrictT
ri Yes &(Nu
I have read the harsndnus matorlals mquiroments under Chapter 6.95 of the Callfor•
nla HCalth & SafetyCedc, Sccdons TSS05, U533 and 25514.1 underrand (hat if the building
does not currently have a lentna, Mat it is my responsibility W notify the occupant of the
mquhcmenuwhich must be �c/ipdorWluu of aCcnilkatcofOccu car.
son[
Signature ofApplicant
roof coverings to be Class "B" or better
Owncr or urtharixcd a cm Data -