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09160081CITY OF CUPERTINO �s�a,� BUILDING DIVISION PERNUT x� � ry BUILDING ADDRESS: PERMIT NO. 10201 AMELIA CT GIA CONSTRUCTION OWNER'S NAME: PERMIT ISSUE DATE CONTROL NO. (408)858-6316 ARCHrrECT/ENGINEEI: 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 (co in with Section 7000) of Division 3 of the Busirness Code, and my license is in full fora and effec ' ADD 5 0 SQ TO ENLARGE (E) FAMILY ROOM INC.LDS o ;�` a Contractor ever STRUCTURAL NO REROOF . CHrtEcrS DECLARA !O I understand my p shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contactors License Law for the following reason. (Section 70313, Business and Professions Code. Any city or county which requires a permit to construct, alter. improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to rite a signed statement thal he is licensed pursuant to the provisions of the Contactori License Law (Cbaprer 9 Sq. Ft. Floor Area Valuation (commenting with Section 7000) of Division 3 of the Business and Professions Codc) or 5 0 0 0 0 that he is exempt therefrom and the bast& for the alleged exemption Any violation of APN Number Occupancy 7t P `� Pe Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or not more than five hundred dollars ($300)L 32617019.00 ❑ L as owner or the property, or my employees with wags astheir role eomn penUoo, Required Inspections will do me murk and the structure is not intended or offered for ask (set:. 70". Business and Professions Code: The Contractors Lx=tm Law does not apply to an owner of property who builds or improves thercon, and who does such wort 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 sak.) ❑ L as owner of the property, am exchuively contracting with licensed contractors to construct the project (Sec 7044, Business and Professions Code:) The Contractors U- cent Law does not apply to an owner of property who builds or improves thereon, and. s) licensed pursuant to the Contrars who contracts for such projects with a contractorcm License Law. ❑ 1 am exempt under See . B & P C for this reason Owner Due 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 WorkeezCompce- station, as provided for by section TM of the Labor code. for the perfa mance 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 Wo Compensation insurance INSURANCE (nds section need not be completed If the permit is for am hundred dollars (S 100) or less) I certify that in the performance of the work for which this permit is issued. 1 shall not employ any person in any manner so as m become subject to the Workers' Compensation - Laws of California. Dam Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Cock, you must forthwith comply with such provisions or this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby airum that there is a construction lending agency for the performance of due work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Lenders Address I certify that 1 have reed this application and state that the above information is cornx:L I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby anthorire representatives of ids city to enter upon the above-mcmioned property for inspection purposes. (We) agree to save, indemnify and keep buml= the City of Cupertino against liabilities, lodgments, costs and expenses which may In any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS D WILL COMPLY WiTH ALL NO -POINT Issued by: Date SOUR ULA770NS. Re -roofs �- Type of Roof 1 �- 0 MATERIALS DISCLOSURE Will the applicant or future building occupant store or hanme hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety Code. Section 25s32ca)? All roofs shall be inspected prior to any roofing material being installed. 0Ye„('�No ❑Yes If a roof is installed without first obtaining an inspection, I agree to remove Wla the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Ara Air Quality Management all new materials for inspection. District? ❑Ya 14No 1 have read the hazardous materials requiremems under Chapter Q95 of the Califor- nia Health & Safety Code, Sections 25505. J5533 and Z5534. I urtdcraarrd atif do building dos not currently have a tenant, dent It tr y responsibility b natty e o t of the requirement which must be met piorto of ' tauj P Signature of Applicant Date All roof coverings to be Class '%'` or better ov,nero<L, orvtdage nt ,q CITY OF CUPERTINO BUILDING PERMIT I BUILDING ADDRESS: 10201 AMELIA CT OWNER'S NAME: 1 SANTA CLARA, CA 95050 1 PHONE NO: (408)858-6316 1 dLICENSED CONTRACTOR'S DECLARATION License Class Lic. # () A ?"? 3 Contractor /�—�� Date N �, ti ( —D--1 I hereby affirm provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I have and will maintain a certificate of consent to self -insure for Worker's Compensation, 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 Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 1 certify that 1 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 construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. + Signature �� _ Date 1 ( or ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: I have and will maintain a Certificate of Consent to self -insure for Worker's Compensation, 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 Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is connect. I 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. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r MECH r RESIDENTIAL r COMMERCIAL r JOB DESCRIPTION:ADD 50SQ TO ENLARGE (E) FAMILY ROOM INCLDS STRUCTURAL NO REROOF. 10/05/2009 - REVSN- ADDITION & REMODEL REVSN TO Sq. Ft Floor Area: I Valuation: $50000 APN Number: 32617019.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued Date/e;;`/_t-G<- RE-ROOFS: 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: 0'• M ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. Owner or authorized agent: Date: CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION 1 understand my plans shall be used as public records. Signature. Date Licensed Professional