060602303=
CITY OF CUPERTWON.
DIVISION PERMIT
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BUILDING
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BUILDING ADDRESS:
PERMIT NOO 6 O 6 023 O
10255 LOCKWOOD DR
OWNER'S NAME:
PERMIT LSSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHFrECT/ENGINEER:
BUI INO PERMrrrNFO
B ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that I 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.
REVISION TO PERMIT #06030057
Contractor License Class o
ate naelor
Dnte
REVISE 1ST & 2ND FLOOR PLANS, STRUCTURAL
ARCHITECT'S DECLARATION
1 understand my plans shall he used as public records
Licensed Pnofessional
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 Cale: 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 file a signed statement
that he is licensed pursuant to the provisions of the Contractors Licenser Law (Chapter 9
Sq. Ft. Floor Area
Valuation 0
(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
Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
five hundred dollar
not more than (SSOO)_
3M4016.00
Q 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the wort. and the structure is not intended or offered for salt (Sec. 7044. Business
and Professions Coda The Contractors License Law does not apply to an owner of
property who builds or improves thereon, 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
sale.).
1, as owner or the property. am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code) The Cootractoh L l-
cease Law does not apply to an owner of property who builds or improves thereon. and .
who contracts for such projects with a rnntractos(s) bcensed pursuant to the Contractars
L;cease Law.
Q I am exempt undo Sec , B& P C f reason
�1 Due
one of the following deciarations:
❑ 1 haoc and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance 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, or the Wormance of the wort for which this permit is issued
My Workers pt n I a carrier and Policy number are:
Card r!1Polity
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed if the permit is for one 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 o the Workers' Compensation
Laws of Caliform'a.1hm {..f�/ n
���
Applicant �•}�
NOTICE TO APPERX". Tf. after mNdng this Certificate of Exemption, you should
beeortte subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AOENCY
I 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.)
Leaders Name
,
Lender's Address
I certify that I have read this application and sere that the above information is
coned I agree to comply with all city and county ordinances and sate laws relating to
building construction, and bcmby aulhorim representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemoiry and keep harmless the City or Cupertino against
liabilities, judgmcnts,costs and expenses which may in any way accrue against said City
in consequence of the granting of Otis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
�% )
Issuedby: Date /L O G
SOURCE ROE u.�O
Re -roofs
Type of Roof
i�l A cs_
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MATERIALS DISCLOSURE
Will the applicant or future building occupant at m or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section25532(a)T 11
All roofs shall be inspected prior to any roofing material being installed.
Q Yes ?F] No
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or future building occupant use equipment or devices which
emit haratdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
YesNo
I have read the haxnt,.,,s materials requiremcns under Chapter 6.95 of the Califor-
nia Health & Safey Code, Sections O5. 255 d 25534.1 rstand that if cite building
does not current, Mtc a it is onslhility, to, notify the occupant of the
mqu;reine cot t
Signature of Applicant Date
k
All roof coverings to be Class "B" or better
ow rvrdagcm D