08090092CITY OF CUPERTINO
BUILDING DIVISION PERMIT
TRry t �y k
BUILDING ADDRESS:
-
PERMIT NO.
21751 GRANADA AVE
MIRAGE CONSTRUCTION
08090092
SANITARY NO. CONTROL Nil.
(408)496-0159
ARCHrIFCTIENGINEFR:
BUILDING PERMrr INFO
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 700D) of Division 3 of the Business and Professions Code, and my license is
REVISION FIRE REQUIREMENTS OR I G
forceeffect.Lie.
,STRUCTURAL ,
ut`� ►
07020112 NO NEW PERMIT'.
Date Conracfar
ARCHITECTS DECLARATION
I undctataad my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for rho
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a pcmtit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed stawmrnt
chit he is licensed to the the Contractor's License law (Chapter 9
Sq. Ft- Floor Area
Valuation
pursuant previsions of
(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 rarnption. Any violation of
Number
35717056
Occu anC T e
P Y YP
Section 7031.5 by any applicant for a permit subject/ the applicant to,civil penalty Of
not more than five hundred dollars (S500).
.
❑ Las owner of the property, or my eraployces with wages as their solic compensation.
e
Required Inspections
will do tle work• and the strucum is not intended or offered forsale (3=7044,Busintasa
and Professions Code es The Contractor's License Law dotrot apply to an owner of
ns
q p
property who builds or improves thereon, and who does such work hlms if or through his
own employees, provided that such Improvemenu ere Got intended or offered for Sala u,
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 contraelan to
construct the project (Sec. 7044, Business and Profasslons Code:) The CtmiracLora LT-
.
tense Law does not apply to an owner or property who builds or Improves thereon, and
who convects for such projects with a contractor(s) Bc mwd pursuant to the Contractor's
License Law.
❑ I
❑ I 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 lasurance, as required by Section
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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.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nis section reed not be completed if the permit is fat one hundred dollars ($100)
or less)
I cc U y that in Like performance of the work for which this permit is issued, I shall not
employ any pe any manner to become subject to the Workers' Compensation
Laws of Cal' omi
Applicant
NOTICE TO PUCANT: If, after making this Certificate of Exemption, you should
become subject to the Workers 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 dare is at construction lending agerucy for the performance of
the work for which this permit is issued (Sec. 3097, Cir. C.)
Lenders Name
,
Lender's Address
I certify that I 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 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.judgmcnu, costs and expenses which may in any way accrue against said City
in conscilumce of the granting of this permit.
APPLICANT UNDERSTANDS
applicant or future building occupant atom or handle haardous mamrial
as dellncd by the Cupertino Mun' 'pal Code, Chapter 9.12. and the Health and Safety
Code, Scction 25532(a)7
All roofs shall be inspected nor to an roofing material being Installed.
P P Y g g
❑Yes No
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 contaminan defined by the Bay Area Air Quality Management
all new materials for inspection.
Disurict7
El Yes Nc
read the hazardous materials requirements Chapter 6.95 of the Califor-
I have requirements under
nia Health & Safety Code. Sections 25505. 25533 and 25534.1 urtders and Dist if Iha building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
req : which must occu
Signature of Applicant Date
All roof coverings to be Class's" or better
O or uLharvc agent ate