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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
20400 STEVENS CREEK BLVD
TBD — TO BE DETERMINED
07110052
OWNER'S NAME:
PERMIT ISSUE DATE
VERONA HOMEOWNER ASSOC
12/11/2007
PHONE
SANITARY Na - CONTROL NO.
ARCHI-[ECP/ENGINEER:
BUILDING PERMITiNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 700U) of Division 3 of the Business and Professions Code. and my licenscis
REPAIR DECK BEAMS & SUPPORT POSTS
in full force and effect
License Class Lic. N
Date Contactor
ARCHITECI-S DECLA
ndcr�tand p shall bGc rcco
Lu ro(essroael
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following nxsort. (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 to its issuance, also requires the applicant for such permit to file a signed starcment
he licensed to the of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that is pursuant provisions
0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 3 5 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
llmbei
3 6 9 010 2 `d f
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more dtan rive hundred dollars (ssoo).
8
❑ L 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 sale (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 wort himself or through his
own employees, provided that such improvemems arc 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. .
❑ L as owner of the property, am uclusively contracting with licensed contactors to
construct 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, mid,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License law.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of tie following declarations:
❑ 1 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
wort for which this permit is issued.
eve and will maintain Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
My Welkker�Clo_mpe�na'ayl11011 IInsuran car�riyer�and Poll cy nuvnber are
Carrier. Jl'yv�\e'! "mot "PolicyNo.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compacted if the permit is for one hundred dollars ($100)
or Iran)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any mannerso as to became subject to the Workcrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: Ir, alter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Lahor Code, you must
forthwith comply with such provisions or this peanit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C-)
'
Lender's Name
,
Lender's Address
1 certify that I have read this appllcatiou and state that the above information is
correct I agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authorize representatives or this city to enmr upon 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 accrue against said City
in consequence of the tin of this permit.
APPLICANT A S AN I WiTH ALL NON -POINT
Issued by: Date
SOUR ULATI
Re -roofs
Type of Roof
Signal UContraclor Date
HAZARDOUS MATERIALS DISCLOSURE
'11 the applicant or future building occupant store or handle hazardous material
-
as defined by the Cupertino Municipal Code. Chapter 9.1Z and the Health and Safety
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yee &W-
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or future building occupant use equipment or devices which
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emit hazardous air contaminants as dcfmcd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes [
I have mad the hazardous materials requirements under Chapter6.95 of the Cali for.
nia Health & Safety Code, Sections 75505, 25533 and 25534.1 understand that if the building
does not currend aN that it is my responsibility to notify the occupant of the
requirer ich must be prior to " 'ficem of Occupancy,
Signature of Applicant Date
All roof coverings to be Class "B" or better
Dam
0 arized agent