08020013CITY OF CUPERTINO
BUILDING DIVISION PERNUT
Bu,LDf8tffTSGREENLEAF CT LOT 3
OWNER'S NAME:
CUPERTINO
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ARCHITECr/ENGINEE R:
PERMIT NO.
NEXGEN BUILDERS, INC. 08020013
GREENLEAF LLC 1 225 DEMETER ST
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
vith Section 7000) of Division 3 of the Business and Professions Code, and my license is
n full force and effect.
.Icense Class Lie. M
)ate Contractor 'r R ��
ARCHITECTS DECLARATION
1 understand my plans shall be used as public n;cords
-icenscd Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
'ollowing reason. (Section 7031.5, Business and Professions Codc: Any city or county
which requires a permit to construct, alter. improve. demolish, or repair any structure
srior to its issuance. also requires the applicant for such permit to file a signed stmernent
chat he is licensed pursuant to the provisions of the Contractors license Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Businessand Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 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. 7044, Business
and Professions Code The Coutrnaoes License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
awn anployca, 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 net build or improve for purpose of
sale-).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
constrict the project (Sec. 7044, Business and Professions Code:) The Contractor's L)-
cense law does mot apply to an owner of prapeny who builds or improves thereat, and .
who contracts for such projects with a contnctor(s) licensed pursuant to the Comnctors
License Law.
❑ I am exempt under Sec . B g P C for Win Rsson
owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury fine of the following declarations
❑ I hive 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.
❑ I have and will maintain Workds Compensation Insunna, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is rued.
My Workei85oom on Insurance artier and Policy number am:
rri Caer. ✓ ` `i��rl �bPolicy No.: 71 f 0Q e(2/-2 7
CERTiFICA7E 0 Pi70N FROM WORKERS'
COMPENSATION INSURANCE
CML& section need not be completed if the permit is Fortino hundred dollar (3100)
or less)
I certify that in the performance of the west for which this permit is issued. 1 shall not
employ any person in any manner o as to become subject to the Workers' Compenntion
Uses of California. Date
Applicant
NOTICE TO APPLICANT. If, after making 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
I 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
Lenders Address
I certify that I have read this application and state that the above infor madun is
correct. I agree to comply with all city and county ordinances and state laws relating to
Wilding construction, and hereby authorize reprucnatives of this city to enter upon the
above -mentioned property for inspection purposes -
(We) agree o save, indemnify and keep harmless the City of Cupertino against
liabilities, judgmc cosy sod espertscs which may in anyway accost against said City
ins consequenco o the gnrtting of this permit.
APPLICANT INDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
RE ATIO 3 — % ^ O C
(o Q
Aqir�u o pplianl/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store orhandle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes OV.
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 'flit No
za 1 have mad the hazardously materials requirements under Chapter 6.95 of the Califor-
nia Health &Safe ode, Sdxtiau 25 25533 and 25534. I understand that if the balding
dots not torten have a tenant. that my responsibility to notify the occupant of the
pege(femcr Teri muss he l issuance of a Crltifieate of Ocgrpaney0 (i 1
(650) 322-5800
PERMrr ISSUE DATE
SANITARY NO. CONTROL NO.
BURRING PERMIT INFO
BLDG ELECT PLUMB
Job Description
REVISED FLR PLANS,SETBACKS,ARCHITECTURAL,SEE LTR
FROM MARK GROSS & ASSOC -ORIG #07020040 NO NEW
PERMIT. CORRECTED APN ORIG PERMIT 32633107.03-NEW
Sq. Ft.
32 65 6 02 9 jVk Number
rssued by:
Re -roofs
Type of Roof
$0
Required Inspections
Valuation
Type
Date
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
Date