08030096CITY OF CUPERTINO
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BUILDING DIVISION PERMIT�:.
BunTETTEIS,ESCENT
CT. , LOT 4
KELLY GORDON-DEVELOPMENT
08030096
OWNER'S NAME
eORP
PERMIT ISSUE DATE
KELLY GORDON DEVELOPMENT CORP
12241 SARATOGA—SUNNYVALE RD
04/01/2008
PHONE:
SANITARY NO. CONTROL NO.
(408)873-8774
ARCHITECTIENGiNEOL,
BUILDING PERMITINI70
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
e
Job Description
of Chapter 9 (commencing
1 hamby affirm that I am lialm" under provisionso
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
ADD 400' DECK .
in full fora and effort.
License Class Lie. s
Date. Contractor
AREH—r EcrS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conumces Little I.aw for the
following mason. (Section 70315, Business and Professions Code: Any city of county
which requires a permit to construct, alter, Improve. demolish, or repair any strumum
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed to the of the Contractor's License law (Cbapta 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
Section 7000) Division 3 of the Business Professions Code)
2 5 0 0
(commencing with of and or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 2 617 0 0 9 ,V
O
Occupancy P cy Type
Section 7031.5 by any applicant for a permit subjects the applicant o a Civil penalty OfNumber
not mom thin five hundred dollars (550). 0
❑ 1, As owner of the property, or my employees with wages as their sok compensation,
Required Inspections
will do the work, and the suucmm Is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Contactors License Law does not apply to an owner of
property who builds or improves thereon, and wbo doesouch work himself or through his
own employees, provided that such improvements are not intended or offered for sale. ll:
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.).
.
owner of the property, am exclusively contracting with licensed contractors to
o6onstruct the project (Sec. 7044. Business and Professions Crede:) The ContrAcules U.
cense Law docs not apply to an owner of property who builds or Improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant o the Contractor's
License Law.
❑ 1 �t See , B& P C t reason
O Date
ORKER'S COMPENSAno
I AT m under penalty of perjury one of the following dedarationc
I hive and will maintain a Certificateof Consent to self -insure for Worker s Compere
sation, as provided for by Section 3700 of the Libor Code, for the performance of the
wort for which this permit is issued
❑ I have and will maintain Workers Compensation Insurance as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance artier and Policy number am:
Carrier. Policy No.:
CERTIACATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the perk is for one hundred dollars ($100)
or icss)
I certify that in the perf ante of w rk for which this permit is issued. I shill not
employ any person in any m become sat ' Compewdom
Laws of California. Date
Appli
NOTICE TO APPLI ter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this petmit shall. be deemed revoked
CONSTRUCTION LENDING AGENCY
I 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 Namc
Leader's Address
1 certify that 1 have read this application and slate that the above information is
-
correct. I 'Agra 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
'��4
liabilities, judgments,coss and expenses which may in any way accrue against said City
In comaequernce o ting of thrix peril
APPLICA lilt NDS AND WILL COM I ALL NON -POI
Issued by: Date
SOURCE
Re -roofs
Type of Roof
S of Applian retractor Me
ARDOUS MATERIALS DISCLOSURE
the applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safcty
Code, Section 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building ampant use equipment or devices which
emit hazardous air commninants'as defined by the Bay Area Air Quality Management
all new materials for inspection.
Distr(ct7
❑ Yes
1 e hazardous materials requirements under ter 6,95 of the Califor-
nia H th & Safety 'ons 25505, 25533 and 25 . un d that if the building
deet no ndy have a an at i . y ' it notary the occupant of
requbcmentsw m us=m to ofOc -
Signature of Applicant Date
All roof coverings to be Class In" or better
' Date "
er or autho agent