06100183CITY OF CUPERTINO�
BUILDING DIVISION PEFMT
,
BUILDING DDRESS:
PERMIT NO.
10W MILLER AVE
TBD — TO BE DETERMINED
06100183
:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
70b Descri tlOn
P
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DO) of Division 3 of the Business f - ns Code. and my 1�=is
lClass d �
NEW S FDVLJ— 1-ST -STORY: 14 6 4 ' , 2ND STORY: 811 ' ,
License Lie.11 �Z _
PATIO (C) : 314 ' , PORCH (C) : 167 ' , GARAGE: 427 '
Date ARc �s DECL Ano
GARAGE: 4271 X 56.318 = $ 2 4 0 7 4 .2 6 — —SEE BELOW
1 understan my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law 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 applicant for such permit to file a signed statement
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the previsions of the
Section 7000) of Division 3 of the Business and Professions Code) or
$ 5 3 0 2 8 9
(commencing with
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number.
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SM.
3 7 5 0 5 0 3 9. U U
❑ 1, 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 forsale(Sec.7044,Business
and Professions Code: The Contractor's License Law des not apply to an owner of
q P
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 tot 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 Comraunrs Ll-
conse 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 Contractor's
License Law.
❑ 1 am exempt under Sec , B & P C for this mason
Owner Date
.
WORKER'S COMPENSA7ION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
' n, as provided for by Section 3700 of the labor Cook, for the performance of the
wo for which iris permit is issued.
❑ 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 Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed lithe permit is for one hundred dollars ($100)
or less)
1 certify that in the performance of the work for which this permit is issued, 1 shad not
employ any person in any manner so to One subject to the Worked CompensationLaws
of California. Dat
become subject to the Workces Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be dccmcd revoked.
' CONSTRUCTION LENDING AGENCY
+ 1 hereby affirm that there is a construction lending agency for the performance of
y the work for which this permit is issued (Sec- 3097. Civ. C.)
Lender's Name
"
Lender's Address
I certify that I have read this application and state that the above information is
+ correct. 1 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 City of Cupertino against
y
liabilities, judgments costs and expenses which may in any way accrue against said City
in consequence of the granting of this grlt.
+ APPLICANT UNDERST S W ' COMPLY WITHZALLJF'N-P
SOURCE REGU
Issued
Dae
US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defied by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section25532(a)7
Yes
All roofs shall be inspected prior to any roofing material being installed.
❑ KN.
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 hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
1 have read the hazardous aerials immcnts under Chapter6.95 ofthe Califor-
nia Health & Safety Code,
Applicant Date
All roof coverings to be Class "B" or better
Owner a owed rat-