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CITY OF CUPERTINO77777777
PERMIT�TITQ��T�'
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BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
10535 FELTON WAY
—
TBD -TO RE DETERMINED
J0_9 0 1012 2
OWNER'S NAME:
PERMIT ISSUE DATE
J
S CONTROL NO.
ARCHITECf/ENGLNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
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 Bustin cu oC =d my license is
force
DEMO FD (15 0 0 SQ
in full an L
License Clap.Lam•
Dam ContractorL
.c.
ARCHrMCI'S DECLARATI N
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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
Sq. Ft. Floor Area
Valuation
! prior to its issuance, also requires the applicant Car such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Contractor's License (Chapter
(commencing with Section 7000) 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 arty applicant for a permit subjects the applicant to a civil penalty of
APN Number
Occupancy Type
not mere than five hundred dollars ON.
35918C11.00
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q lI
will do the work and the structure is not intended oroffered 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li.
cense Law does not apply to an owner of property who builds or improves themon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under See. B & P C for this mason
OwnerDate
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 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ I have and will maintai W rker's Compensation Insurance, as required by Section
3700 of the Labor Code, C performance of the work for which this permit is issued.
My Worker s Com o urance carrier and Policy number am:
Carrier Policy No.:
CER FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars ($100)
or less)
I certify that in the perform c of the w rk for hich this permit is issued, 1 shall not
employ an • n in any as ecu to the Workers' Compcnsadon
Laws I all i
Applicant
NOTIC PPLICANT: 1 , a makin this ertrfii 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 mvokcd.
j
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.)
Lender's Name
L.cndees Address
I certify that 1 have read this application and state that the above information is
correcL 1 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
y above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
n liabilities. judgments. costs and expenses which may in any way steric against said City
7 in consequence of the granting of th' rmiL
-+ APPLICA ERS NDS D W]LL COMPLY WITH ALL NON -POINT
Z
Issued by: DateN.
SOUR G
Re -roof's _
sig are of A IicanttConuactor Date
HAZARDOUS MATERIALS DISCLOSURE
T of Roof
Type
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 Safety
Code, Section 25532(a)?
All roo 's shall be inspected prior to any roofing material being installed.
❑Yes OXO
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 contaminsns as fined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes Nu
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505" 25533 and 25534.1 understand that if the building
does not currently have a len!56 that it is my responsibility to notify the occupant of the
requirements wh' ofaccritficatelifocc9ancy.
Signature of Applicant Date
All roof coverings to be Class 'W' or better
Owner ora zcd agent Dam