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CITY OF CUPERTINO
BUILDING DIVISION PERMIT�1I
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BUILDING ADDRESS:
PERMrr NO.
10735 ORLINE CT
TBD — TO BE DETERMINED
07080116
OWNER'S NAME:
PERMIT ISSUE DATE
12/05/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHI ECrIENGINEFR:
BUILDING PERMIT INFO
- BLDG ELECT PLUMB - MECH
LICENSED CONTRACTOR'S DECLARATION
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Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 ofthe Businessand Professions Code, and my license is
REVISION — ROOF CHANGE — ADDING ROOF TO FRONT
in full force and effect
License Class Lic• 0
PORCH
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afli m that 1 am exempt from the Contractors License Law for the
following reason. (Section 703 U 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 file a signed statement
that he is licensed to the of the Contractors Lkcne Law (chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
0
m (comencing 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
,�,p: Number
r
Occupancy
panC y T�pe
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($som.
35922060 V
❑ I, as owner of the property, or my employers with wages as their sole compensation,
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Required Inspections
w01 do the work and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Code; The Contractors Lx=m law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employers, provided that such improvements are not intended oroffered for sale. If,
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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.).
❑ L as owner of the properly, 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 to the Contractors
License haw.
❑ I am
DECLARATION
I hereby affirm under penalty of perjury, one of the following declarations:-
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compcn-
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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
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My Workers Compensation Insurance carrier and Policy number are:
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Canr{er. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for one hundred dollars (S100)
or less.)
1 certify that in the performance of the work for wh" this permit is issued, I shall not
employ any
Labor Code, you must
fortbwith 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 wok for which this permit Is issued (Sec. 3097. Civ. C)
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Lender's Name
Lenders Address
I certify that 1 have read this application and sate that the above information Is
correct I agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorize representatives of this city to enterupon 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 in any way acme against said City
in consequence of the granting of thi it.
t�^�
/1 %
APP CAM U ERSTA S WILL COMPLY W ALL ON -POINT
Issued by: Date
®
Si"of Applian on Date
HAZARDOUS MATERIALS DISCLOSURE
WW the applicant or future building occupant store or handle hazardous material
as defined by the Cupenino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
El Yes QW6__
If a roof is installed without first obtaining an inspection, I agree to remove
Wi11 the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfnncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes
1 have read the hazardous materials mquimmenu under chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the building
des no eurrenfy bars a tenant T'shu my responmbdily m notify the a upant of the
c is whk ust met 'o t issuance of a Certificate of cy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or
thonvtd agck Date
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