07120243CITY OF CUPERTINO
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BUILDING DIVISION PEPMT
BUILDING ADDRESS:
PERMrr NO.
1-506 PRIMROSE WAY
TBD - TO BE DETERMINED
01120243
OWNER'S NAME:
PERMIT ISSUE DATE
:
SANITARY NO. CONTROL NO.
ARCHIIF-Cl'/ENGiNEF.R:
BUILDING PERMITINFO
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LICENSED CONTRACI.OR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DD) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lie.
Data Contractor
ARCHrI'ECCS DECLARATION
I understand my plans dull 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 mason. (Section 7031.5, Business and ProfessionsCak: Any city or county
which requires a permit to construct. -alter, hnpmve, 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 L ccnx 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 vloWiou of
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars (S500J.
❑ L as owner of the property. or my employes with wages as their sole compensation,
will do the work, and the structure is not intended or offered for ask (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 We. 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70". 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 contracta(s) licensed pursuant to the Conuaetors
L.kense Law. .
❑ I am exempt under(Sec. , B k P C for this reason
ownr�a(/lo Vli M Date
WO 'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following deciaruimic
❑ I hive and will maintain a Ceutificato of Consent to self -insure for Worker's Compen-
sadon, 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 Workers Compensation Laurance carrier and Policy number are:
Carrier: Policy Nim
CERTIFICATE OF. L XEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any Penton in any in roilrQe subbet to the Workers' Canpcasatlon
Laws of California.
Esempdon, 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 revoked.
CONS7RUCnON 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
Lender's Address
1 certify that I have toad this application and state that the above information is
torten- 1 agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorim representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agme to save, indemnify and leap harmless the City of Cupertino soon
liabilities. judgments. cops and exponecs which may in any way scare against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS A WILL COMPLY WITH ALL NON -POINT
SOUR REGULA
MATERIALS DISCLOSURE
Will the applicant or future building occupant pore or handle haardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑Ye. No
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
DisaicO
[3 Yes No
1 have read the l mdous materials rcquharncnts under Clap," 6,95 of tic Califor-
nia Health k Safety Code, Sections 25505.25533 and 25534.1 understand this if the building
does not currenty.bave ■ t, that It is my responsibility to nodfy occupant of the
mquirgmem s whkh mi i prior to issuance of a Certifisata�oMtvpinejt
Job Description
ADD 880' LIVING RM,OFFICE,MASTERBATH,GAME RM.
PORCH 36'-REMODEL 80' 2 BATHROOMS
Sq. Ft. Floor Area $200000 Valuation
36615018.
Required Inspections
Occupancy Type
Date
Re -roofs (/
Type of Roof
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';4" or better
Date: