08050059fury OF CUFKK1 N0
BUILDING DIVISION PERIMT
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BUILD N D S: -- - -- — I PER MIT NO.
28�6°�ESGREENLEAF CT LOT 2 NEXGEN BUILDERS, INC. 08050059
OWNER'S NAME: PERMIT ISSUE DATE
CUPERTINO GREENLEAF LLC 225 DEMETER ST 05/13/2008
PHONE: SANITARY NO. CONTROL N0.
(650) 322-5800
ARCHTT-ECTIENGINEER: BUILDING PERMIT iNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing Job Description
with Section 70M) of Division 3 of the Business and Professions Code, and my license is REVISION TRUSS CALC S —STRUCTURAL FOR FRAME
in full force and a L.N-7b q q 2_GS
License Class
ORIG#07020039—NO NEW PERMIT
Date Contracinr N G-e Ul
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARA71ON
I hereby affirm that I am exempt from the Conractnrs Uccnse Law for the
following moon. (Section 7031.5, Business and Professions Code: Any City or county
which requires a permit to construct, slier, 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 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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (s50"
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the work_ and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code: The Conuaeloes Li ense 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 be did not build or improve for purpose of
sale.).
❑ L as owner of the property, am allusively 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 Contractor's
License Law.
❑ 1 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:
❑ I lui a 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 Workers 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 am:
C."i 60 ATP Policy No.: 7 / 9 0� 27
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars (S I00)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so m to become subject to the Workers' Compensation
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: 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 prnvisons or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, C+v. C.)
Lender's Namc
Lender's Address
I certify that I have read this application and state that the above information is
correct 1 agree to comply with all city and county ordinances and slate laws relating to
building concoction, and hereby aurhorin representatives of this city to enter upon the
above-mandoned property for inspection purposes
(We) agme 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 permlL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUi�`RFGw GfIS. zt _ .S _ l7 o�-
Signature of ApplianU(9Co�nttra-1ccwr 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 Safety
Code, Section 25532(a)?
❑ Yes ..eVo
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
District?
[] Yoe 6VNo
I have read the hazardous materials requirements under Chi prcr 6.95 of the Califor.
nia Health & Safety Code, Sections 25305, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requ(rcm which must cl pno is uwcc of a CcrtiOcatc of Occupancy.
3T I.. � S'— 1 1�) -o1b'
Sq. Ft. Floor Area 1 $ 0 Valuation
32656028A? TNumber
Required Inspections
Issued by:
Re -roofs
Type of Roof
Type
Date 3-- l J��
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
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class'na' or better
Owner or authori7l d agcnF Date