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CITY OF CUPERTINO
PERMIT
BUILDING DIVISION
BUILDI G ADDRESS:
27_71 KENDLE ST
TBD — TO BE DETERMINED
PERMIT NO.
08040186
OWNER'S NAME
PERMIT 15E9UE DATE
:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER.'
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
licensed Chapter 9
Job Description
I hereby affirm that I am under provisions of (commencing
with Section 70M of Division 3 of the Business and Professions Code, and my lilecasc Is
ADDITION 948 S Q FT MASTER BEDRM , BATH, BONUS ROOM
UeeriscoL�asand effect Lic.x YkZ
REMODEL - 663 SQ FT BATH, KITCHEN, FAMILY ROOM
Date Contractor
ARCHITECTS DEC TTON
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I bcreby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70315, Business and Professions Code: Any city of county
which requires a permit to construct. slter, Improve, demolish, or repair any structure
prim to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 2 0 0 0 0 0
that he is exempt thraefmm and the basis for the alleged exemption. Any violation of
32 613 105. 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 (SS00).
0 L as owner of the property, or my employers with wages its their sole compensation,
Required Inspections
will do the work. and the structure is not intended or offered for sale (sec. 7044, Business
The and Professions Code: Contractnes License Law does not apply to an owner of
property wbo builds m improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended oroffered forsale. 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 m
construct the project (See 7044. Business and Professions Code:) The Contractors U-
cease Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
.
0 I am exempt under Sec . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 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
work for which this permit is issued.
❑ 1 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 Workers Compensation Insurance carrier and Policy number ��
� r �
•-ROM WORKERUT
COMPENSATION INSURANCE
(This section need Trot be completed if the permit Is for one hundred dollars ($100)
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 manner so as to become subject to the Woriters' Compensation
Laws of California Doc
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Libor 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.)
Lenders Name
Landers Address
,
1 certify that I have read this application and stare that the above information is
correcL I agree to Comply with all city and county onfinences and state laws relating to
building construction, and hereby authotire repnsentasives of this city in enter upon the:
above -mentioned property for inspection purposes
(We) agree to save, indemnify Tod keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way acenre against said City
in consequence of the granting of thin permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
.
r�
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
/
Type of Roof
Signal of ApplicantlCoaractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will an 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, Section 25532(a)?
❑yes �No
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfrncd by the Bay Arts Air Quality Management
all new materials for inspection.
District?
❑ Yes AN.
1 have read the hvardous materials requirements under Chapter &95 of the Califor-
nia Health & Safety Cade, Sections 2MM 25533 and 25534.1 understand that if the building
does not Currently have a renant, that it is my responsibility to notify the: occupant of the
requirements
_