07020112 CITY OF CUPERTINO .r ', >ta�a ,�y+„�. g -+z ,a =w :
BUILDING DIVISION PERMIT �+�L'kJ,.l\t'1. 1A� •��'a`��
BUILDING ADDRESS: PERMIT NO.
21751 GRANADA AVE TBD - TO BE DETERMINED 07020112
SANITARY NO. CONTROL NO.
ARCHI'IEC rENGINEER: BUILDING PERMIT INFO
NEW 2 STORY TOWNHOUSE-1, 702 ' BD O PLUMB O
3oa LICENSED CONTRACTOR'S DECLARATION Job Description
touchy affirm that 1 am licensed under pmru vinoof Chapter 9(commencing •^-^^ ^^`
Z with Section 7010)ofDividoe 3 of the Bud••..and ProlbW...Code,andmylimeseis
^_ in full forte am efrm
License Class Lle.N
S Dau Convenor
eQ4 ARCHRECI-S DECLARATION
,c O I understand my plans shall he used u public rec had,
Isd G Licensed Proftnummal
3 OWNER-BUILDER DECLARATION
E 1 hereby Affirm that 1 am exempt from tho Contractors License Law for me
I:ao following muoa(Sato 7101.5,Business;and Professions Code:Any City Ar countyrd$ which roq.a..pvmtr m maul racL Alun Improve.demolish.er repair any structure
_Z�- print b is Issuance."sedpdm requires the the applicant for such pecmil m rile a signed stelemem
p w Nnhm is A,itsaW nquiresprovisiansnfthe such ecmrunJanulaw(Ch.pur9 Sq.Ft, FloorArea Valuation
i€9 (commencing with Section 7000)of Division 3 of the Business and Professions Coca)or
Q —
that he u eampt rh^ssfrom and the basis for the alleged exemption.Any vWatl m of
Section 7011.5 by ary appllant for a permit subjects the applicant m a doll penally of APN Number Occupancy Type
Act mom Nu five helldmd dollars($SW).
❑
I.an owmr of 0z property.a my empiayme with wagu a thekmle compenasdon,
wmdothewark..ndd,eawnuml wtiomndedaafferedfaa.le(sa.7an,Buineas - Required Inspections
And Prof calms Cad.T.Contractors License Law man not apply m an Owner of q P
propertywho bulldsorimprevet dmman.ked who doaauch work himselfor Waugh his
own emplayrce.provided that such improvemrn s arc not Intended arafiered forsale.If. -
however,the building or improvmnent is sold within arc Inner ofcompleton,the owrcr-
builder will Mass the burden of proving that W did act build or improve for purpose of
isle.).
,A.owner of the property.am euludvely,confuting with licensed mnuxtors m
eomimel the poodle"(See. ion 7044,Business and ProfessCode:)Th Cootr es U.
mum Law does not apply in an owner of property who Wilds or improves Ihesean,ted.
who con away for such projects with a conuutor(q Seemed pursuant to the Conu.cmM1
License Law.
❑lamnem undo See B&P C far thin mason
wan
I hembY.Birm under pensltY of perjury oro of the fallowing decluatoru:
❑I have and will maintain a Cerdfinmaf Castntue self-inumfaWorker'sCompen-
sadon,u provident for by Section 3700 of the labor Cade,for die peAorm.na of the
work for which thin permit is issued.
❑I have and will maintain Workers Compensation Insurance,As required by Section
37M of tiro labor Cade.for the performance of the work for which this permit In luWA
My Workers Compemadan I....artier and Potcynumber am:
Carrier Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ITissectton need an,n completed if the permits forane hundmddolWs(SIM)
or lex)
I anifY that in the perfarmaao of the work fa which this permit is issued.I anal not
employ any person in any marc sou acme subject to the Worker CompeuNon
.
laws of C�Nfu.I Dam .a
Appllant�JJ�/il al-.w�
NOTICE TO APPLICANT:If,after making this Certificate of Exceniadillm,you shauW
become subject in the Workers Compensation prevision of the LAW Co&you mute
O O forthwith comply with such providow or this permit shill M deemed resulted.
CONSTRUCTION LENDING AGENCY
[-n I Aemby allim this Nem Is a comnnedon lending agency for the perfunnuwe of
ori> the work for which this permit Is usual(Ser.3097.Civ.C.)
W�Q Lender.Name
r7 z Lenders Addrnt
U O 1 comfy that I haw mad this application mrd sum that the above information is
LL cortrnt.I agree As comply with all city and county omloancea and state Ise relating ue
building cersuved...And hereby authorise mpnsenutlws of Nis city in emerupnn W
W ahave-mentioned property for inspectan pugmses.
(We)agme to uvea indemnify and keep harmless the City of Cuperino alsorut
N Ilabilides judgments,case and expenses which may in any way carne against said City
U in consequence of the Spending of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Data 4
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or futum building occupant arose or handle hazardous material
As dennad by Ile Cupertino Municipal Code.Chapter 9.13.and the Health and Safely
Adie.Secure 255334)7 All roofs shall be inspected prior to any roofing material being installed.
❑Ya �Na
WIII to applicant or forum building occupant tau equipment or Ileviaa which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conumimnts As defined by the Bay Ama Air Quality Management all new materials for inspection.
District? ��ss
OYes 9[ld.
I hero mm the harardnusmaterials requisemems under Ch tina,695 of W Califor-
meHan&Safely Coda,Sectom 255D5.25533 ea125534.1 muleramnd that ifthe Wilding
Dau
COVERSHEET
07020112-D
21751 G RANADA AVE