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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
11236 PALOS VERDES CT
TBD — TO BE DETERMINED
07040073
OWNER'S NAME:
PERMIT ISSUE DATE
08 30 2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
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with Section 70DO) of Dividon 3 of the Business and Professions Code, and my license is
S FDWL - 2 STORY 4 12 4 ' LIVING, 4 5 9 ' GARAGE, AND 6 6 '
in full fora and effect.
,
License Class Lic. a
PORCH, BASEMENT 1 2 7 4 '
Date Contractor
,
ARCHITECTS DECLARATION
t understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter. improve, demollsh, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the of the Contractors License Law (Chapter 9
Sq Ft. Floor Area
Valuation
pursuant provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Codc) or
.
$ 9 810 4 8
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
not more than five hundred dollars ($500).
35621033
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered fersalc (Sec.7044, Business
and Professions Code- 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 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.).
as owner of the property, am exclusively contracting with licensed contractors to
nsuuct 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 thereon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1
OwDate
WORKER'S COMPENSATION DECLARATION
I 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.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
370D of the Labor Code, for the performance of the work for which this permit is issued
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My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be 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 manner so as to become subject to the workers' Compensation
Laws of California, Date
Applicant 6
NOTICE APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Codc• 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 (See. 3097, Civ. C.)
Lenders Name
,
Lenders Address
I certify that I have read this application and state that the above information is
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correct 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(Wc) agme to save, indemnify, and keep harmless the City of Cupertino against
liabilitias, judgmens,cow and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N-POINT
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Issued by: Date
SOU UI ATIOIYS. D
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Re -roofs C7�L
Type,of Roof
Signature olApplianUConuactor Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mumeipal Code- Chapter 9.12. and the Health and Safety
Code, Section zss3z(a)?
All roofs shall be inspected prior to an roofing material being installed.
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[3 Yes o
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 d ncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand thatif the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements ust be met p'L isauancc ora Certirteato niece.
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Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or authorized agent Date