02050195BUMDING DIVISION PERMIT
BUILDING ADDRESS:
1155 KENTWOOD AV
o�RAMxA
f PHONE:
ARCHITECTIFNGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 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 Lic. p
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (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 toils issuance, also requiresthe applicant for such permit to file a signed statement
hei he,is:jicedsed pumuirit to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 70M),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 byany applicant for a permit subjects the applicant to a civil penalty
:of not more than five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will -46 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 improves thereon, 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 will have the burden of proving that he did not build or
improve for purpose of sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (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 contracts. for such -projects with a contractor(s) licensed pursuant to the
Contractor's License Law.
ElI 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 -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
111 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. ' 'Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This;section need not be completed if the permit is for one hundred dollars
(Sloo) or less.)
I certify that in the performance of the work for which this pemdt is issued, I
shall not employ any rson in any manner so as t e e e sub' t ig the Workers
Compensation La
provisions of the Labor Code, you must
forthwith comply with such v' ions or this permit shall be 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 is issued (Sec. 3097, Civ, C:)
L.ender's•Name ' .
Lender's Address' _
1 certify that 1 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 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 against
liabilities, judgments, costs and expenses which may in any way accrue against said
City in c asequence of the granting ','of this permit.
APIPJ�T�gT UNDERSTA'v'DS A.�D WILL COMPLY NNITH ALL NON_POL\T
Y MATERIALS DISCLOSURE
Will the applicant gr future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes ' I'❑ No ,
\7111 the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not currently have a tenant, that it is my responsibility to notify the
occupinyof the requirements which musi be met prior to issuance of a Certificate'of
�I
PERMIT NO, 2 0 5 019 5
APPLICAT1l6J11�IjB.DR.T$ 2 0 0 2
SANITARI VNO. // SS 11 // CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I I C=1 C. 7 I I
ADD 489 SQ . FT . Job Description
c
10 APN NE&bWD
102 - PIERS
104
105
106
202
203
204
205
301
302
303
304
305
306
307
308
309
310.
311
313
501
502
503
504
505
506
507
508
509
510
514
Issued by:
Re -roofs
Type of Roof
$65000
Url;Ell Required Inspections
REBAR
ANCHOR -BOLTS
- SEWER & WATER
UNDERFLOOR PLUMBING
UNDERFLOOR MECHANICAL
- UNDERFLOOR..FRAME _-
- UNDERFLOOR INSULATION
- ROUGH PLUMBING
- TUB & OR SHOWER
- ROUGH MECHANICAL
- ROUGH ELECTRICAL
FRAME
- HOLDOWNS
- INSULATION
SHEETROCK "-
EXTE'RI OR , LATH
- INTERI.OR LATH
-SCRATCH COAT
- ROOF NAIL
- FINAL ELECTRICAL- -ENERGY
- FINAL PLUMBING ENERGY
- FINAL MECHANICAL ENERGY
- FINAL BUILDING ENERGY
FINAL ELECTRICAL
GAS TEST
- FINAL PLUMBING'
- FINAL MECHANICAL
- FINAL GRADE
- FINAL PLANNING
- FINAL PUBLIC WORKS
Date
Type
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
all new materials for inspection. Applicant understands and will comply with
all non -point source regulations.
Signature of Applicant Date
All roof coverings to be Class rB" or better
OFFICE