08070138CITY OF CUPERTINO
X
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10`_i44 ORANGE TREE LN
CRITCHFIELD CONSTRUCTION
08070138
OWNER'S NAME:
PE10,I1T ISSUE DATE
845 S MCGLINCY LN
08/26/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHrrFCf/FNGINEER:
BUILDING PERM1TrNFo
ADD 347 TO KITCHEN FAMILY ELECT
o 0 0 0
LICENSED CONTRACTOR'S DECLARATION
b Descrlptlon
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
^ ^ ^ ^^ ^_. ..., .,....,_ _._ _.53
with Section 7000) of Division 3 of the Business and Professions Cnge, and my license is
in full force and effect.
U enSC lass Lk. ih
DBte CDmtractar G
CHITECI-S DECLARATION
1 understand my putts shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Conuaciors License I4w 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 appliaru for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License raw (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
ane
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty or
not more than rive hundred dollars (:sou)
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work_ and the structure isnot intended oroffered for sale (Sec.7014,Busines,
and Professions Code: The Contractors License Law does not apply to in owner or
q p
property who builds or Improves thereon, and who does such wort himself or through his
own employees, provided that such improvements rte 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. 7014, Business and Professions Code:) The Contractors u-
eonse I4w 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
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaradorw
❑ 1 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
wofor which Ibis permit is issued
ave and will maintain Workers Compensation Insurance, as required by Section
of the Labor Code, for the performance of the wok for which this permit is issued.
My Workers Compensation Insurance carrier and Policy nurn are:
Carrier: A{•� arary l l (461 .FA C' Policy No.: C 1 11 �
CERTIFICATE OF EXEMFnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred doBPrs (2100)
or less)
,
I certify shot U the performance of the work for which this permit is issued, l shall not
employ any person in any man re as !t a e subjg to the Worker' Compensation
Laws of California
Applicant
NOTICE TO APPLI : If, Fier making this Certificate of Exemption, you should
become subject to the Worker's mpensadon provisions of the I.4bor Code, you must
forthwith comply with such provisions or this permit shallbedecried revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a eomstructinn lending agency for the performance of
the work far which Otis permit is Issued (Sec. 3097, Civ. C.)
.
Lenders Name
Lenders Address
I certify that I have read this application and state that the above information is
cored 1 agree to comply with all city and county ordinances and state Is" relating to
building construction, and hereby authorise 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 acerae against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
�% 1
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Signature of ApplicanVConuactor pate
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
W1B the applicant or future building occupant store or handle hrndous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
Code. Section 25532(a)7
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 frubuilding occupant use equipment or devices which
Will the applicant or fir building occupant use equipment or devices which
emit ha Ardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspecti
District?
❑ Yes
Ihaw mad the requirement,tmderChapter6.95oftheCalifor-
JL
d
ma Hcajth& SafetyCodc. Sections 25505.25533 and25534.1 u dersiand thatif the building
n it is my responsibility to tiry the Occupant or the
does not currently have a law, that ro
requircnicmts which must bc mel prior to issuance of a Cctrficale of Occup'
Signature of Applicant Date
All roo coverings to be Class'%" or better
Date '
Owner or authorized agent