08030174BUILDING DIVISION PERMIT CONTRPliC�'�R I��4_FK.1VUA11UFA:
Bulu�I� AN LEANDRO AVE ITBD - TO BE DETERMINED
:
ARCHITECT/ENGINEER:
i O p LICENSED CONTRACTOR'S DECLARATION
m C I hereby affirm that I am licensed under previsions of Chapter 9 (commencing
7 U (� with Scclion 7 ODO) of Division 3 of We Business and Professions Code, and my license is
' y in full force and effect
r 12 Z License Class Lic. N
F, p Date Contractor
ARCHITECTS DECLARATION
7 I understand my plans shall be used as public records
>yU
O. y Licensed Professional
O OWNER -BUILDER DECLARATION
fA
i I hereby affirm that I am exempt from the Contractors License Law for the
-CO 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
Z y prior to its issuance, also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9
O (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of
not more than five hundred dollars (S500).
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structme is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contract ies License Law does not apply to an Owner of
property who builds or improves thereon, and who does such work himself or through his
own ernployem 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
sa/le.):
[,L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The Contractors Ld-
cense Law does not apply to an owner of property who builds or improves thereon, and
/� !��! Date �� o
I hereby afrum under penalty of perjury one of the following declarations -
El I hsvc and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation, 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 Worker's Compensation lasuramz, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
My Workers Compensation Insurance carrier and Policy number are.
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars (S I00)
or less.)
I certify that In the performance of the work for which this permit is issued, I shall not
employ any person in any m � bccom bject to the Workers' mpensation
Laws of California. Dare
Applicant
NUtIICE TO APPLICANT: If, after making o E this Certificate xemption, you should
become subject tothe Workers Compensation provisions of the Labor Code, you mast
Z fwbwith comply with such provisions or this permit shall be deemed revoked
O CONSTRUCTION LENDING AGENCY
-r i--r 1 hereby affirm that there is ■ construction Lending agency for the performance or
> the work for which this permit is issued (Sec. 3097, Civ. C-)
Zi Q Lenders Name
3.
= z Lenders Address
0 I certify that I have read this application and state that the above information is
I. correct I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposm
y a (We) agree to save, indemnify and keep harmless the City of Cupertino against
y V) liabilities, Judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit
APPLICANT J44DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici al Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
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
District?
❑Yes �lA`ro
1 have read the hazardous materials requirements under Chapter 6.95 of theCalifor-
nia
Date a —
PERMIT NO.
08030174
PERMIT ISSUE DATE
06/10/2008
SANITARY NO. CONTROL NO.
BURRING PERMIT INFO
BLDG ELECT PLUMB
Job Description
SFDWL-2 STORY 3,485, GARAGE 624'—ALL ROOF PITCHES
TO MATCH. NO ACCESSORY STRUCTURES IN FRONT
SETBACK. THE CONC PILLAR IN THE FRONT SETBACK IS
Sq. Ft. Floor Area $400000 Valuation
3 570502 6 .)RN Number
Required Inspections
lip
Issued by:
Re -roofs
Type of Roof
Occupancy Type
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class'W' or better