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CITY OF CUPERTINO
BUILDING DIVISION PE
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BUILDING ADDRESS:
ALVAND CONSTRUCTION
PERMIT NO. 05100080
22561 RICARDO
OWNER'S NAME:
PERMIT ISSUE DATE
10413 TORRE AVE.
12 06 2005
PHONE:
SANITARY NO. CONTROL NO.
(408) 781-7620
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
JobDescri CIOn
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
P
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and cffecL
REVISION - MASTER BEDROOM & FLOOR PLAN & MASTER
License Class Lic. N (7Z✓
Date Contractor
BATH FLOOR PLAN REVISION
ARCHITECTS DECLARATION
NO NEW PERMIT ISSUED/ORIG. #04060137
I understand my plans shall be used ss public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contrwors 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 to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I. as owner of the property, or my cruployces with wages as their sole compensation,
Required Inspections
will do the work. and the structure is not intended or offered forsale (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 oroffered forsale. 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
cense 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 Contractors
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:
❑ l 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
work for which this permit is issued.
❑ I 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 caries and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed If the permit is for one hundred dollars ($100)
or Icss.)
l certifv that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, 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 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.)
'
Lenders Name
,
Lenders Address
1 certify that 1 have read this application and state that the above Information is
corecL l 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
Iiabilities,judgmems, costs and expenses which may in anyway accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDEfgfqjjSTAN S ND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safely
Code. sptYes 25532(a)?
All roofs shall be inspected to any roofing material being installed.
11J�Ne
prior
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 Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safcly Code, Sections 25505.25533 and 25534.1 understand that if the building
a1e