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CITY OF CUPERTINO
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BUILDING DIVISION PEl
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BUILDING ADDRESS:
GARY HALL
PERMIT N b 4.0 tj 0 0 3 1
10227 S FOOT
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
ADD 600 S Q FT (GUEST. HOUSE)
License Class Lie. It
. .
Date Contractor
RC AHITECI-S DECLARATION
-
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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, demolish, or repair any structure
prior W its issuance, also requires the applicant for such permit W file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
arO 0
Occupancy Type
PanC Y YP
not more than five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as thew sole compensation,
Required Inspections
will do the work and the structure is not intended or offered forsele (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply W 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 compaction, 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 contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors 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 W the Contractors
L' nse
ILA rcby affirm under penally of perjury one of the fol eclarations
❑ I 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
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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fllnis section need not becomplced if i e permit is for one hundred dollars (EIOO)
or less)
I certify that in the performance fthe work for which this permit is issued, I shall not
employ any person in
Laws of Califomir. Be
Applicant
NOTI E APPCICA If, a r raking is Locate of Exc ptio ,you ould
11
boo object to the ompensation provisions of the Labor Code, you must
forthwt 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.)
Lender's Name
Lenders Address
1 certify that I have read this application and state that the above information is
correcL I agree to comply with all city and county ordinances and state laws relating W
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
r (We) agree to save, indemnify and keep harmless the City of Cupertino against
t liabilities, judgments, costs and expenses which may in any way accrue against said City
/•,
i inconsequeA�ufthclingfthis pertniLAPPLICAAND AND Vj it. rC0 tY WITH ALL N�N•PgINT
SOURCjS. / /
Issued by: Date
+
Re -roofs
Type of Roof
Si rc'of Ap lican on or Date
/p AZARDOUS MATERIALS DISCLOSURE
Wilf'4e applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code- Chapter 9.12. and the Health and Safety
Code, section 25532(a)7 '�!
❑Yes No
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
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
all new materials for inspection.
District?
❑Yes /N�u
1 have read the ha7ardous materiais rcquiremcnts under Chapter 6.95 of the Califor-
niaHealth&Safety Codc, Sections 25505,25533 and 25534. 1 understand that ifthe building
does not cur�anmamt.Lhatitism ponsibilily W notify Ile oc upon o(thcrequirementsW
cc nificatc afCccu cy.
r
SignatUX6 Of pplicant Date
All roof coverings to be Class "B" or better
Owncrorauthori- dagc
are