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CITY OF CUPERTINO
PERMIT'��
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BUILDING DIVISION
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BUILDING ADDRESS:
21919 CORTE MADERA LN
TBD - TO BE DETERMINED
PERMIT NO.
08060063
:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section7000)ofDivision 3ofthe Business and Professions Code, and mylicense ia
D (1220SQ) FAMILYRM, KITCHEN, BEDRM, BATH&LAUNDRY—REM
In full fora and effwL
License Class ue.1l
D (1220SQ) FAMILYRM, KITCHEN, BEDRM, BATH&LAUNDRY-REMO
Date Contractor d .,. /Nz.
SDECLARATION
�(1220SQ)FAMILYRM,KITCIiEN,BEDRM,BATIi&LAUNDRY-REMOD
I understand my plans shall be used as public records
Licensed Pmf.Wonal
OWNER -BUILDER DECLARATION
I bcmby 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 at permit to construct, alter. Improve, demolish, or repair any structure
'
prior to its issuance, also mquirrs the applicant for such permit to file a signed statement
conuactoes L'cease Law (Chapter 9
Sq Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
Division 3 the Business and Professions Cade) or
.
$ 2 2 0 0 0 0
(commencing with Section 7000) of of
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
N Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($50o}32645036.
V U'
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required lied Inspections
will do the work. and the structure is not intended or offered for salc (See. 7044. Business
and Professions Code The Comnctoes License Law does not apply to an owner of
q
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 not build or improve for purpose of
sale.).
.
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
an owner of property who builds or improves thereon. and .
cense Law does not apply tonere
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 reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of potjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compen.
salon, as provided for by Section 3700 of the labor Code, for the performance of the
work 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 Wor s Compensation Insurance carrier and Polity nMarc:
Comer rA eel P7 44 n��G it Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section need not be completed If the permit Is for one hundred dollars (S 100)
or less.)
1 certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensaton
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, aftermaking this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, 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.)
'
Lendcrs Name
Lenders Address
1 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 City of Cupertino against
j Liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:S4(zaw Date 2
. Z2 / L
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Will the applicant or future building Occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Sec25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Yes No
Yes
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?
No
❑ Yes
1 have read the hazardous materials requirements under Chapter6.95 of the Cali for.
nia Health & SafetyCodc, Sections 25505.25533 and 25534. I understand that if the building
does not currently have a
be Class'}'' or better
' Date '
Owner autho agent