09030001y00
;oto
BMW
Z
1! LU
to
�yU
;tea
ny-a
p0
—Z>
iFo
z Q
z�
r.r
GLi ?
Cl. Q
�z
UO
wN
O
U
H �
U
CITY OF CUPERTINO
BUILDING DIVISION PERNIIT
v T cTa , 11
BUILDING ADDRESS:
PERMIT NO.
20874 GARDEN GATE DR
TBD - TO BE DETERMINED
09030001
SANffA CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
ADD 3 6 0 SQ TO 2 (E) BDRMS , ROOF
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
STRUCTR OVR EXTNG TO Job Description
1 hereby affirm that I 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. A
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70315, 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
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any 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,
Required Inspections
will do the work. and the structure is not intended oroffered for sale (Sec.7044,Business
and Professions Code: The Conunctoes License Law does not apply to an owner of
ns
q P
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 o! 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
tract 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 thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ 1 B& P C for
_this /maassoon
Owner `%/� " Date
WORKER'S COMPENSATION DECLARATION 1
hereby affirm under penalty of perjury one of the following declarations:
❑ I ham 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 Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars (3100)
or less.)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any per '
Exemption, you should
become subjeFtld the Worker's Compensation provisions of the Labor Code, you must
forthwith cordMy with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
,
1 hereby affirm that there is a construction lending agency for the perfurmance of
the work fur which this permit is issued (Sec. 3097, Civ. C.)
Lendees Name
'
Lcndees Address
1 certify that I have read this application and state that the above information is
corecL 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
ahove-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 consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON
Issued by:
-POINT
Date
onlrae
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 Safety
Cade, Section 25532(a)?
❑Yes No
All roofs shall be inspected prior to any.rooffng material being installed.
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 f LNu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a enanL that it is my responsibility to notify the occupant of the
M ua nus which must be met prior to issuance o! a Certificateof Oc pansy.
Signature of Appl ieant Date
�%-7/02
r ..
All roof coverings to be Class 4" or better
- '' —�
orautho
Qwn ems
.edag