06040054'ITY OF CUPERTINO
BUILDING DIVISION PERMIT``-'
BUILDING ADDRESS:
10585 JO
OWNER'
ARCHITECT/ENGINEER:
i O Zp LICENSED CONTRACTOR'S DECLARATION
w I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
< °• in full fora and effect.
j License Class Lic. N
3 F, w Date Contractor
ARCHITECT'S DECLARATION
9 a -1 I understand my plans shall be used as public records
)y V
e uO H Licensed Professional
= N OWNER -BUILDER DECLARATION
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1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason. (Section 7031.5, Business and Professions Code: Any city or county
ofi which requires a permit to construct. alter, improve, demolish, or repair any struc ure
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> prior to its issuance, also requires the applicant for such permit to file a signed statement
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< that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
r1-- m (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
i .. that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant fora permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500}
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.70", Business
and Professions Code: The Conuactoes 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 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.).
[!fI, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70". Business and Professions Code:) The Contractor's Li-
cense law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exem under Sec , B & P C for thinreason
COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Conscnt to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Tabor Codc, 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 are:
Carrier. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($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 m anneysqhC�me subject to the Workers Compensation
Laws of Califyyj�
this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
Z CD CONSTRUCTION LENDING AGENCY
j •+ 'CA•+ 1 hereby affirm that there is a construction lending agency for the performance of
7 the work for which this permit is issued (Scc. 3097, Civ, C.)
W Q Lenders Name
D. LendcrsAddress
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U O 1 certify that I have read this application and state that the above information is
VL '-'' torten. I agree to comply with all city and county ordinances and stale laws relating to
O U building construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposes.
Ll.t (We) agree to save, indemnify and keep harmless the City of Cupertino against
Hen liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL CCMPLY WITH ALL NON -POINT
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HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstorc or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
Cl Yes gNO
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 eNo
1 have read the hazardous materials requirements under Cha filer 6.95 of the Califor-
nia Health & Safety Code, Sections 25505. 25 533 and 255 34. 1 undcrsrand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant or the
rc
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Owner or authorized agent _ Doc
LIC
(408)393-1484
PERMIT N00 6 0 4 0054
PERMIT ISSUE DATE
07/11/2006
SANITARY NO. CONTROL NO.
Job Description
BUILDING PERMIT INFO
ELECT PLUMB
SFDWL 2 STORY - SQ FT. 2284; GARAGE 400 SQ FT
SANITARY IS SUNNYVALE'S JURISDICTION
Sq. Ft. Floor
37rj3'70-527:00
Required Inspections
IssL:ed b•r•
Re -roofs
Type of Roof
'Date
Va
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 "B" or better