08040064CITY OF CUPERTINO
PERAUT
BUILDING DIVISION
BUILDING ADDRESS:
10384 MELISSA CT
TBD - TO BE DETERMINED
PERMIT NO.
08040064
R'S NAME:
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHTTECT/ENGTNEER:
BUILDING PERMIT INFO
KTCHN RMDL, STRUCTRL INCLD
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 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class - Uic. I
-
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conuactors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construe, alley, improve, demolish, or repair any su=um
-
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 Ixcnsc I" (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 700D) 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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
and APN Number Occupancy T
P Y YPe
not more than five hundred dollars (S=00).
L as owner of ttie property, or my employees with wages as their sole cornpensadon,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business -
Required Inspections
and Professions Code: The Contractor's License Law does sot 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 w10 have the burden of proving that he did not build or improve for purpose of
sale.).
W. as owner of the property, am exclusively contracting with licensed contractors to
@onstnict the project (Sec. 7044. Business and Professions Code) The Contactors Li-
.
cc= 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 Contractor's
License Law.
1 am
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 37DO of the Labor Code, for the performw= of the
work for which this permit is (sued
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Isbor Code, for the performance of to wort for which this permit is issued
'
My Workers Compensation Insurance carrier and Policy number are:
Carrier. , Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(ibis section need not be completed if the permit is for one hundred dollars (S 100)
.
Cyr Irss_)
I certify that in the performance of the wort for which this permit is issued, 1 shall not
employ any person in
of the Labor Code, you must
forthwithcomply with such provisions or this pctmil shaltbe deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit fa issued (Sec. 3097, Civ. C.)
Lender's Name
,
Lenders Address
I -certify that 1 have read this application and state dal the above information is
correct 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise 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,judgmcnts, costs and expenses which may in arty way accmc against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
the apptant or future building occupant store or handle hazardous material
deftrtod by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
IF ode. ❑ Ya section 25532(a)7 �Jo
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 hwcardous air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes
lb ave mad the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & Safety Code. Sections 25505.25533 and 25534.1 understand tat if the building
does not currently have a email that it is my =,ponsibility to notify the occupant of the
requimmentswhichm_ycyb�metprior toissuance ofaCertificate ofoccupyncyy.
Signature of Applicant Date
/ 0
All roof coverings to be Class ",W' or hetter
owner or aUUnONLo agent tactic