09090031CY OF CUPERTI]
BUILDING DIVISION
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BUILDING ADDRESS:
10309 BRITT
OWNER'S NAME.
:
ARCHITECT/ENGINEER:
1 hereby affirm that 1 am licensed under provisions of Cbapter 9 (commencing
with Section 7000) of Division 3 of We Business and Professions Code, and my license is
in full force and effect.
License Class Lic. 0
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 71731.5, Business and Professions Code: Any city or county
which requires a permit to roruarwt, alley, improve, demolish, or repair any structure
prior 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
(commenting with Section 7000) of Division 3 of the Business and Profestions Code) or
that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031.3 by any applicant for a permit subjects Lite applicant to a civil penalty of
not mote than five hundred dollars (SM
❑ L as owner of the property, or my employees with wages as their sale compensation,
will do the work. and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Cade: The Contractors 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 art not Intended or offered for sale. ff,
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.).
ZIL as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code;) The Contractors U.
cense Law does not apply to an owner of property who builds or improves thercon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt
DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 haver 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 Workers Compensation Insurance as mq uired 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 me:
Carrie: Policy No.:
CIR TIMCATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
ODhu section need trot be completed if the permit is far one hundred doll= (S 1011)
or less)
I certify that in Lite performance of the work for which this permit is issued. I slnll not
employ any person in any manner so as to become subject to the Workers' Comperuadon
Laws of California.
this Certificate of Exemption, you should
become subject to the Workers Compensation provisioru of the Labor Code, you must
forthwith comply with such provisions or this permit shall be decaied revokcd.
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 (Scc. 3097, Civ. C)
Lenders Name
L nders 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 convection, and hereby wthor m representatives of this city to enter upon the
above -mentioned property for Inspection purposes
(We) agree to save, indemnify and keep harmless time City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said Cty
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
:7_to - 0
0
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oavpam store or handle haardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)1
❑ Yes );O
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Qwatty Management
District?
❑Yes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505, 25533 and 25534_ I understand that litho building
does not currently have a rerant, that it is my responsibility to notify the occupant of the
requirements which must he met prior to issuance of a Ccrtfkatc of OccthpncCy.
PERMIT NO.
PERMIT ISSUE DATE
S CONTROL NO.
BULIDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
REMODEL 190 SQ FT TO. •150 SQ FT TO KITCHEN, 40 SQ
FT TO BATH, ADD 4 SKYLIGHTS, REPLACE THE ALL
WINDOWS, ADD SINGLE HUNG WINDOWS IN FAM, M.SUITE,
Sq. Ft. Floor Area
Valuation
APN Number Occupancy Type
36930018.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
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's" or better
Owner or au