06060124CITY OF CUPERTINO
BUILDING DIVISION PERMIT�;�`�Q'
BUILDING ADDRESS:
FRANCIS & MARGARET KEELER
PERMIT NG-06060124
22405 BALUSTROL CT
OWNER'S NAME:
PERMIT ISSUE DATE
:
SANITARY NO. CONTROL NO.
ARCHnECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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 Business and Professions Code, and my license is
in full fora and errIt
Uccnse Class Lie. p -!;-'.:• -`' '�-
ADDITION TO THE FRONT BEDROOMS 2 7 0 '
Date 7-- a.G ^ o Contractor •'✓
ARCHITECTS DECLARAT ON
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
,
I hereby affirm that i am exempt from the Contractors 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
$ 5 7 8 7 9
prior to its issuance, also requires the applicant for such permit to file a signed statemem
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5i500).
❑ I, 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 or offemd for sale (Sec. 7044. Business
and Professions Code: The Contractors 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 arc 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.).
❑ 1, as owner of the property, am exclusively 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 cone actor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B A P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hs ve 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 Workers Compensation Insurance carrier and Policy number ace:
Carrier. M �T Policy No.;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compkied if the permit is foram hundred dollars (S 100)
or less)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of .
Applicant
NOTICE TO AfPLICANT: If. after making the 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
y 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.)
Lenders Name
'
,
Lenders Address
I certify that I have read this application and state that the above information is
^ 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
above -mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
P)) 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 �— ZG' U
�� 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
25532(a)? 0
Code, Section two
Yes
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
Will the applicant or future building occupant use equipment or devices which
emit barardous air contaminants as defined by the Bay A= Air Quality Management
all new materials for inspection.
District? �.
❑Yes O'No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if dte building
does not currently hale a tenant, that it is my responsibility to notify the occupant of the
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