07110102az
0
IU5
:z uj
< c.
.�h
,2z
!a
�yU
U.
a e
NJ
OC
Iry
-Za
CITY OF CUPERTINO
7
'O;RMAT'IUN'"
BUILDING DIVISION PERAUT
G NTR�iCTQR_I
cul I (ppR
TBD — TO BE DETERMINED
07118.102
OW S NAME:
PERMIT ISSUE DATE
06/11/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINFER:
BumDING PERMIT INFO
-BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARA71ON
Job Description
I hereby afrwro that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 cram Business and Professions Code, and my license Ls
NEW 2 STRY S FDWL , 4 316 LUNG, 672 GARG , 45 PORCH
in full font and effect
License Class Lie. 0
.
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used its public records
L)censed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 70315• Business and Professions Code: Any city at county
which requires a permit to Construct. alter. improve• demolish• or mpair any innicture
prior to its issuance• also requires the applicant for such permit to file a signed statement
that be is licensed pursuant to the provisions of the Conuacmrs License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
Section 7000) Division 3 of the Business and Professions Code) or
$964839
(commencing with of
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 5 6 0 8 0 5 5 Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars (S5oo1
❑ L as owner of the property, or my employees with wages as their sole compensation.
Required fired Ins esti O n S
q
will do the work. and the structure is not intended or offered for sale (Sec. 7044• Business
and Professions Code: The Contractors License Law don not apply m an Owner or
P
property who builds or improves thereon. and who dots such wart himself or though his
own employers. 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
salc..
L as owner or the property. am exclusively contracting with licensed contiaaats to
ntruct the project (Sec 7044, Business and Profusions Cade) The Contaictnrs L; -
cease Law don not apply to an owner of propety who builds at improves thereon. and.
'
who contracts for such pmjects with a contractor(s) licensed pursuant to the Contramafa
-
license Law.
❑ I am "crop oder See B"PcC for ts
'
/,°fin
Owner r Data
PENSATION DECLARATION
1 bemby aQirrn an ty of pvjury one of the fallowing declamtiotss
❑ 1 have and will maintain a Ceniiieom or Consent m self -insure for WorkersCompen-
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• For the performance of the work for which this permit is Issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier. Policy Na.:
CERTIFICATE OF L -7(F2 FnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed U the permit u far one hundred dollars (510(Y)
or less.)
1 unify, that In the perrormance of the work for which this permit Is Issued. 1 shall not
employ arty person ecu to the Wo ' Comp -on
[,awn of Califo
Applicant —
NOTICE TO �kPFUCANF.11. after m 's rtificate of F�cernptian, you shoo d
become subject m th s Compensddo vision of the Labor Code, you must
' forthwith comply with such provision tv unit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby drum that there is a eonsiructian lending agency for the performance or
' the work for which this permit Is issued (Sec 3097• Civ. C)
Lenders Name
Lenders Address
I certify that I have read this application and suite that the above information is
+ correct I agree to comply with all city and county tmlinanm and state laws elating to
building construction• 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 agarol
I liabilities judgments• costs and expenses which m in any way accrue against said City
e in consequence of the granting of this
APPLICANT UNDER STAffDS-A,% IL" Co PLY WITH ALL NO -POI
Issued by: Date
/( �G 9
/
/
Re -roofs
Type of Roof
Signad&c arwppli Comr.DO Di1C
cern 1scl.osuRE .
W(II the applicant or fuuue building occupant store or handle hazardous material
'
as defihed by the Cupertino Municipal Code. Chapter 9.12and the Health and Safety
,
Code. Section 25532(a)7 ��///
[:1 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 defused by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes jNo
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health Ss Safely Code Section 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant. that it' nsihilhy to notify the Win the
mquimmenuwhich to u ofaCertirieatcof0c panty
Signature of Applicant Date
1 Sx
�,m�
All roof coverings to be Class's" or better
Owner tn sent
s aa