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BUILDINGDIVISION PERT
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BUILDING ADDRESS:
PERMR NO.
10185 EMPIRE L
TBD — TO BE D
'
OWNER'S NAME:
PERMIT ISSUE DATE
0 QK
SA Y CONTROL NO.
ARCHITECrfENGINEER:
BUILDING PERMIT INFO
NEW 2STORY SFDWL—LIVING
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
2,736' GARAGE 431' L �escrip[ion
1 hereby afBtm that 1 am liccnvd under provisions of Chepmr 9 (commencing01Sb
with Section 70110) of Division 3ofNe Business and Profession, Code. and my license is
in full force and effa s.
U.. Class Ue. as
'
Dam cmur.cm,
ARCHITECT'S DECLARATION
I understand my plans ahall be used a public recoda
Userued Pmfestiosil
OWNER -BUILDER DECLARATION
1 hereby strove Nat 1 am exempt form the Conlnnah License Law for the
rellowing moon. (Section 7031.3. Business and Profess oro; Cale: Any city or county
'
which team. s Permit to cnnareeL almr. Impr.ve. demolish, s mpoir say wucmte
prior b i, issuance. aku requires ted applicant faramh permit m ftk a signed statement
Ft. Floor Area
Valuation
Nat W is licensed pursuant to the provisiomaftM Conpacese. license Law (Chapter 9
Sq.
(comma neing wish Section 701f)()) of Division 3 of Ne Business and Profession Cade) at
Nat he as exempt therefrom and the basis for Ne alleged asamption. Any violation of
APN Number
Occupancy Type
P y yp
SeNan 70313 by say applian, far a Permit subject/ dm appikam m a civil penalty of
trot mom thus Rm handrtd dollars (5500).
I, M owner of the property, Or my employees with wages u their sole compensation,
Required Inspections
will cia the work and the sppmme u not intended or offered for axle (Sec. 7004, Business
arta Profession Code The Caatractar, Lissa Law does rot appy b an Owner of
Property who builds a improves Naraom and who aoes,urd cost Itimsalr s Ntougn his
own employees, prevdded that such improvements am out intended compared forsale. ff.
however. the building or improvement is said within ane year of compktion, Ne nwns-
builds Ng have the Nudes of proving that Int did tm WW or improve for puryose of
'
aka).
a owner of Um property am exclusively ccaussa g with lisped convalan m
convect the porjem (Sec 7044. Business and Penfesoom Code) The ConOaemr's U.
cane Law does Out apply W an owns of Propcny, who WWW or imPrem Meson, and.
who eomraets for such projects with a eon,Ymr(s) Restated puramm, m Ne C nVLL10ys
License Law.
❑ sem un C for this moon
nor
DECLARADate
I hereby aRltm under porosity of perjury, one of the following doelantion:
❑ I hsw and w01 mainuiv aCenifiatea(COsient to al( --inure fs WorkefsCanpen-
student, .s provided for by Section 3700 of the labor Cade, far dm performa� of the
work for which this Permit is issued.
❑ I have and will maintain Worker, COmpasiauon Lae., as carpeted by Scedon
3700 of the labor Code, for the peRormanee of the work fee which Nu permit is hoed.
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My Worker, Compensation bsws. carrier and Policy number are:
Carrier. Policy No.:
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(MissoNon rcN rot W completed lr Ne Permit is forms, hundred dollars ($10(i)
Or Ins)
I ccrtify shnt in the parfmmatme of the wart for which this Permit u issued. l ,hall not
Lm an roan In an mMK'r sec as b bocce esY N�,Qrorkers L-alll lion
orwq y& 1 %N/ a/ p
aw Of Cal P
Apmlicant ✓s
N077CE TO APPLICANT If, s along this certificate of Esempoon, you should
become subject b Nc Workers Composition. ptovisiwu of the labor Cade, you am
foMwith comply with such provision or Nu permit shall W docmed revoked.
CONSIRUC"DON LENDING AGENCY.
Ihareby.frnrm shm there uaaanspuctimn leading agent in, the perlonnans of
the work fm which tens Permit u issued (Stu. 3091, Civ. C)
Lcndofs Name
,
1<ndoes Address
1 century that I have sad this application amd sum Nu the .bove information u
I agree ro comply with all city and county oNinarmaa and rote laws calaong m
Wilding compunction. and hereby mlhoiae mmeanmivvs of Nu city W enmrupnn the
above-mentioned property for impaction p sposes
(We) agree to save, indemnify and keep barnoth as Um City of Cameroon a,sint
liabilities, Judgments, coati and expenses which may in any way ams again, said City
in easieq. of Ne gond..Of this pmmil
AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
APPLICANT ULAER�ANDS
Re -roofs
Type of Roof
RDODam
DOUS MATERIALS DISCLOSURE
Will Neapplicant Or (mum Wilding mupatIlam Or accord...material
and Health
a deeded by the Cupertino Municipal Code. Chapter 9.13, and Ne Health and Safety
Code. section 15532(a)7 W
0Yes [n
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
WIII the applicant s future building =.pant use equipmrnt ser devices which
emit hozadous air can,misints u dcfioed by Ne Bay Area Air Quality Management
all new materials for inspection.
Dirtiest
❑Yes Pu
y
I have read Ne haaNau msmriaurequiremenu under Chapmrfi.95 ofthe Giifor-
NUJde Wiring
wHalshGSsfctyCode, Annualuhat
iti my responsibility
does not curtcndy hese . annual. that it u my rcapousiM1ilitY m rwdfY Um azupat or the
req'
am