07080076BUILDING DIVISION PERNUT
PERMIT NO.
BuILDIr$G q 4Dss: CUPERTINO RD SAMUEL CONSTRUCTION 07080076
OWNER'S
NAME:, PERMIT ISSUE DATE
SUNNY.VIEW LUTHERAN HOME 2141 CAROBW
I PHONE: SANrr RY N . CONTROL NO.
z
0 MACIUR' LICENSED CONS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
G with Scaiop, 70W),of Division 3 of the Business and Professions Code, and my licansc is
'L in futl force and c(feet
z License 1ga - Llc.a S� Y-7 7 Z
p Date's a Contractor
ARCHrIECTS DECLARATION
< 1 undcniamf my plans shall be used as public records
U
Liccpscd PruRssional'
-OWNER-BUILDER DECLARATION
1 hcr'eby affirm. that I am exempt from the Contractors Uccnse Law for the
00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requirps� a permit to concoct. alter, improve, demolish, or repair any structure
y prior to its issuance, also requires the applicant for such permit to file a signedstatemcm
0 that he is licensed pursuant to the provisions of the Contractor's Ueeme Law (Chapter 9
o (commencing with Section 7000) of Division 3 of the Busincssand Professions Code) or
. m that he Is exempt therefrom and the basis for the alleged exemption Any violation of
Section'1031.5 by arty applicant for a permit subjects die applicant to a civil penalty of
not more than five hundred dollars (S500}.
❑ 1, as owner of the property. or my employers with wages as their sole compensation,
will do the work. and the structure is not intended or offered for side (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such wank himself or thmugh his
own employees, provided that such improverriens are not intended or oltered for sale If,
however, the building or improvement is sold within one year of completim the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
1, as owner of the property, am exclusively contracting with licensed tmrttraanra to
concoct the project (Sec 7044, 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 contractor(s) licensed pursuant to the Contractor's.
License LA .
Q 1 am exempt under Sec . B h P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and -will maintaio a Certifheate of consent to self -insure for Workers Comport
sation, as provided for by Section 3100 of the Labor Code, for the perform== of the
work for which this permit is issued
l bivc and will maintain Worker's Compensation Insurance, as required by Section
3100 of the Labor Code. for the performance of the work for which this permit is Issued.
My Workers/Coompersatioonn Insurance carrier and Policy number are: --t
Carrier. [ z tit f--r Policy No.: 0 `
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Ibis section rued not be completed if the permit is for orie hundred dollars (S100)
or Irss.)
I certify that in the performance of the work for which this permit is issued. 1 shill oot
employ anypperson in any mariner so as to become subject to the Wortrrs' Compensation
Laws of California. Date
Applicant - -- - ---
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workcfs Compensation provisions of the Labor Codes you must
Z forthwith comply with such provisions or this permit shall be dsrnccd revoked
C
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a concoction lending agency for the performance of
> tie work for which this permit is issued (Sec. 3091, Civ. C)
a Q L.endrfj Name'
3 Z Lender's Address
C I certify that 1 have read this application and sate that the above information is
'—' comet. I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction, and hereby authorize representatives of this city to enter upnn the
abovc~jnontioned properly for inspccdon purposes.
,(We) agree to save, indemnify and keep harmless the City of Cupertino against
y rA liabiIWmjudgmcnts, costa and expenses which may in any way accrue against said Cty
Z ,in consequence -of the granting of this permit
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S69#CE REGULATION&
Sipatpie of App r rate
HAZARDOUS MATERIALS DISCLOSURE
' Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Cliapter 9.12. and the Health and Safety
Code', Section 25532(a)?
❑ Yes j No
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 RIO
l,hmad
ad the hazardou/s maicrials requirements under Chapter 6.95 of the Califor-
nia Health k Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not eurrFnty have a tenant, that it is my responsibility in notify disc occupant of the
requirements which netts; met prior to issuance of a Ccrtifhcate ofOcptpartcy.
(408)249-2828
BUILDING PERMrrINFO
ELECT PLUMB
Job Description
REVISIN —TEMPORARY PERMIT FOR TI COMMERICAL FOR
R2
PROJECT
Ft.
$0
3 2 61512 9ARNumber
Required Inspections
Issued by:
Re -roofs (�
Type of Roof
at)on
Occupancy Type
Date P-0`,- >
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 "Br' or better