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CITY OF CUPERTINO PERMIT
BUILDING DIVISION 17�� �£Yyr�
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BUIC.DINGADDRESS:
K & M DEVELOPMENT INC
PERMITN003060121
10660 SANTA LITCIA RD
OWNER'
(408)253-9787
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Scc'ion 7 ) of Div0 '0'the Business and Profcssions Codc, and my license is
in full force cfle
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DEMO
Licens Q s Lic.k��U
Dale — _ Contractor �% 7Jc�: ✓FGf'i G"
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ARCHITECTS DECLAON
I enders nd my plans shall he used as public records
_
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Busincss and Profcssions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
$10000
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chaptcr9
Sq. Ft. Floor Area
.Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
34216034.00
that he is exempt therefrom and the basis for the alleged exemption. Any violation of'
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($500),
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
—DEMU
Required Inspections
will do the work and the structure is not intended or offered 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
safe,).
❑ I, as owner of the properly, 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 properly who builds or improves thereon, and •
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
'
❑ I am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I 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 maintain Workers Compensation Insurance, as required by Section
,
3700 orthe Labor Code, for the performance of the work for which this permit is issued.
M�y�W�orrkels Compensation Insurance carrie)and Policy numbrl � Z�
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CERTIFICATEOFE EMPTI9 YOM WORKERS'
R' e- OMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($10(1)
or less.)
1 certify that in the performance of the work for which this permit is issued. I shall not
-
employ any person in any manner.so as to become subject to the Workers' Compensation
Laws of California. 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 provisions or this permit shall be deemed revoked.
t CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constructinn lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. CJ
,
� Lender's Name
Lender's Address
i 1 certify that I have read this application and state that the above information is
t correct. 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 -POINT
Issued by: Date
SOURCE CATIONS. 6112
Re -roofs
.
Type of Roof
I �3
Si atn Ic
HAZARDOUS MATERIALS DISCLOSURE
W' meapp�ican"t 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
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes No25532(a)?
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 defined by the Bay Area Air Quality Management
'
all new materials for inspection.
District?
❑ Yes Y
I have read the hazardous materials rcquircments under Chapter 6.95 of the Califor-
nia Health & Safcly Codc, Secduns 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to otify the cc of the
requirements issuance of a Ccroliica of eu an y
Signature of Applicant Date
2 3
All roof coverings to be Class -"B" or better
wncr ur aulhgr'r.c ni ate