03060042BUILDING DIVISION
BUILDING ADDRESS:
TOTAL CONSTRUCTION 7""'"03060042
ARCHITECT/ENGINEER:
00 LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
z U with Section 70(10) of Division 3 of the Business and Professions Code, and my license is
a in full force nd feet
i ? License CI Lic. M
�, p Datc Contractor
„tea ARC ITECI•S DERATJ9N It
i a undcrstand my plans shall he used as puhh ids
)yU
U. Licensed Professional
0 • � OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
po following reason. (Section 1031.5. Business and Professions Code: Any city or county
$ (i which requires a permit to construct, alter, improve, demolish, or repair any structure
z prior to its issuance, also requires the applicant for such permit to file a signed statement
= o that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
d r- (commencing with Section 10D0) 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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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 sale. 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law doss not apply to an owner of property who builds or improves thereon, and.
who contracts for such project with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
136 CYPRESS AVE. I PERMIT ISSUE DATE
(4 0 8) 7 81- 310 9 I SANITARY NO. ' ICONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
,2 STORY SFDWL-HILLSIDE
LIVING SP 2,542 SQ.FT./GARAGE 579 SQ.FT.
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issucA-
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Codc, for the performance of the work for which this permit is issued.
My Workers Compensation Insurancecarrierand Polity number are:
a r: �.�C1w .+ImcPolicy
Crhis section need nor be completed If the permit is foronc hundred dollars (S100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workeri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
D z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
V) I hereby affirm that there is a construction lending agency for the performance of
Y4 > the work for which this permit is issued (Sec. 3097, Civ. C.)
S) 0 Under's Name ,
Lender's
ender's Address
J 0 1 certify that 1 have read this application and state that the above informatiun is
t—' correct. 1 agree to comply with all city and county ordinances and state laws relating to
Vbuilding conswction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposes.
y LL (We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgment, cosu and expenses which may in any way accrue against said City
;) in consequence of the granting of this permit.
APPLICANT /NDER UNDERSTANDS AND WILL COMPLY WITH (�NON-POINT
SOURCE {/I/t/
DISCLOSURE
will the applicant or futurewilding occupantstore or handle bazardous material
as defined by the Cupertino Mu cipal.Codc, Chapter 9.12, and the Health and Safety
Codc, Section 25532(a)?
❑ Yes No
Will the applicant or future uilding occupant use equipment or devices which
emit hazardous air contaminant defined by the Bay Area Air Quality Management
District?
❑Yes No
I have read the hazardous materials requirement under Chapter 6.95 of the Califor.
nia Health & SafciyCodc, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a LenanL that it is my responsibility to otify the occupant of the
requi Fn w ich must
)l44 r00
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IM
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Issued by: 5
Va�4jyn 0 0 0
Occupancy Type
Required Inspections
- FOUNDATION
- PIERS
- UFER
- REBAR
- ANCHOR BOLTS.
- SEWER & WATER
- UNDERFLOOR PLUMBING
- UNDERFLOOR MECHANICAL
- UNDERFLOOR FRAME
- UNDERFLOOR INSULATION
- ROUGH PLUMBING
- TUB & OR SHOWER
- ROUGH MECHANICAL
- ROUGH ELECTRICAL
- FRAME
- HOLDOWNS
- INSULATION
- SHEETROCK
EXTERIOR LATH
INTERIOR LATH
- SCRATCH COAT
ROOF NAIL
- FINAL ELECTRICAL ENERGY
- FINAL PLUMBING ENERGY
- FINAL MECHANICAL ENERGY
FINAL BUILDING ENERGY
FINAL ELECTRICAL
GAS TEST
FIN PLUMB G
NG Date
Re -roofs 514 -(7NAL PUBLIC WORKS
Type ofRoR2 - ROOF PLYWOOD NAIL G
3 - ROOF BATTENS
60 - ROOF IN -PROGRESS
All roofs sha l e inspected prior to any roo Ing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
ignature of Applicant Date
All roof coverings to be Class "B" or better
r
CITY O"r
CUPEkTINO
•
0
City of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: (408) 777-3228
FAX: (408) 777-3333
BUILDING DEPARTMENT
OFFICIAL NOTIFICATION OF NEW ADDRESS ASSIGNMENT
TO: All Agencies
FROM: City of Cupertino
DATE: September 03, 2003
• RE: Address assignment (APN #342-22-044)
Please note the following address assignment. The new house being built on Mercedes
Road lot #44 has been assigned the following address: 22810 Mercedes Road.
The new address will take effect thirty days from the date of this letter. If you have any
questions, please call me at (408) 777-3246.
Sincerely,
Susan Winslow
Administrative clerk
•
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