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CITY OF CUPERTINO
PERMIT
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C. O.W tA,CTQR INF(�RM�t'�'I�N.
BUILDING DIVISION
BUILDING ADDRESS:
PERMrr NO.
7677 PEACH BLOSSOM DR
TBD — TO BE DETERMINED
07090142
OWNER'S NAME:
PERMIT ISSUE DATE
:
SANITARY NO. CONTROL NO.
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
ADDTN 524 SQFT, PORCH 33
BL.DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
,
70 ascription
I hereby affirm that I am licensed under provisions of (commencing
with Section 7000) of Division 3 of due Business and Professions Code, and my license is
„,., -�..., ,,,_ .
in full force and effect.
License Gass Ilc. p
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, sitar, improve. demolish, or repair any suuclum
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt dusmfrom and the basis for the alleged exemption Any violation of
APN Number
OCCU e
Occupancy
P Y �rP
Section 7031.5 by any applicant for a permit subjects the applicant to a coil penalty of
not more than five hundred dollars (SSM
❑ I, as owner of the property, or my employees with wages as their sole compenaadon,
Required Inspections
win do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Codc: The Conttaeloes License Law does not apply to an owner of
properly who builds or improves thereon. and who does such work himself or through his
own employee;, 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
Omits owner of the property, am exclusively contracting with licensed contractors to,
construct the project (Sec. 7044. Business and Professions Code) The Cini actors Li-
cense 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.
012 a
hereby affirm under f perjury one of the following declarations
❑ 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
wort for which this permit is issues.
❑ 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 Worlm('s Compensation Insuraace carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (5100)
or less.)
1 certify that in the performance of the work Or which this permit is issued, f shall not
employ any person in any m cr I be car eci to a Workers' Compensation
'
Laws of California
NOTICE TO : if, after makin Certificate of Exemption, you should
become subject to the Worker's Compenss o provisions of the Labor Codc 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-)
L.endces Name
Lenders Address
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 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 Clty of Cupertino against
liabilities,jadgmcns, coats and expenses which may in any way accrue against said City
iin cat nce
S MATERIALS DISCLOSURE
Will the applicant or building occupant store or handle hazardous material
as defined by Use Cupertino unicipal Code, Chapter 9.12, and the Health and Safety
Code,zs532(a)?
Section o
❑ Yes �L�
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hvzardous air contaminants as defined by the Bay Arcs Air Quality Management
all new materials for inspection.
District?
❑ Yes
I have read the hazardous aterials requiremrnas under Chapter G95 of Una Califor-
niaHeal tlf Safety Code, Sections nderstandthaUtcbuild'
dap t