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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
21737 GRANADA AJIF,MIRAGE
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
A CONTROL NO.
(408)496-0159
ARCHITECT/FNGINEFit:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I no licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Profession Code,and my license is
in full fora and effect.
REVISION FIRE REQUIREMENTS, STRUCTURAL, ORIG
License Class Lk. 0
Date Contractor
07020111 NO NEW PERMIT. SEE PERMIT #08090092 FOR
ARCHfrE= DECLARATION
I understand my plans shall be used as public records
FEES.
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.3, 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 sulemcnt
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
80
APN Number
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5300)
3 5 717 0 5 5 .3 7
C] 1, as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improver theeon, 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 completion, the owner -
builder wUL 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 lcensed contractors to
construct the project (See. 7044. Business and Professions Code:) The Contractor's U-
cease Law does not apply to an owner of property who builds or Improves thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-Insum 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
'
My Worker's Compensation Irtwrarcc carrier and Policy number art:
Carrier; Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for one hundred dollars ($ too)
or loss.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any maucr so as to become subject to the Wor1Mr3'Compensation
-
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed evoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a consuuclion lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
,
Lender's Address
I certify that I 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 concoction, 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, coats and expenses which may In any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signatureof Applicant/Contractor Dab
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant Store or handle haardous material
as dented by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
code, Section2ss3zca)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ❑ No
s
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 ❑ No
I have mad the hanrdous mabrials requirements under Chapter 6.95 of the Califor-
niaHealth &SafeyCode, Sections 25505,25533and 25534.1understand that lflhe building
does not currently have a tenant that It is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Cesifica c of Occupancy.
Signature of Applicant Date
All roof coverings to be Class'W or better
-
Owner or authorized agent Date