07040009OF CUPERTINO
r"ILDING DIVISION PERMIT
,LDING24T9 ESS:
RD
XS NAME:
SUNNY VIEW LUTHERAN HOME
PHONE:
ARCHITECT/ENGINEER:
p cO LICENSED CONTRACTOR'S DECLARATION
WI hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Q "
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
= y in full force and effect Q 6-6877 Z
t v� Z Licen C eJ Lie. R �T - -
C Date /d 0'3 Contractor . 6f? fAOLaKwe(,
ARCHITECPS DECLARATION
i a < I understand my plans shall be used as public records
)o,V
m Licensed Professional
a OWNER -BUILDER DECLARATION
' r 1 hereby affirm that 1 am exempt from the Contractors License Law for the
' C Oy� following reason. (Section 7031.5, Business and Professions Code: Any city or county
$ (i which requires a permit to construct. alter, improve, demolish, or repair any structure
Z ay 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
t- (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 five hundred dollars (5500).
❑ I, 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 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
sale.).
❑ I, as owner of the property. 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 property who builds or improves themon. and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
T am exempt under Sea B & P C for this reason
.er Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury ane of the following declarations:
❑
[have and will maintain a Certificate of Consent to self -insure for WorkersCompen-
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 are:
Carrier. R^i #Jdji d Policy No.: 10224633-
CERTIFICATE OF EXEMPTION FROM WORKERS' 'Zd310
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, I shall not
employ any person in any manner so as to become subject to the Workeri Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT. If, after making this Certificate of Exemption, 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 -
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.)
Lender's Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. 1 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 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
SOURCE p
Signature of Ap canU for Date
DOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous material
tefrned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
de, Section 25532(a)?
❑ Yes YNo
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?
❑ Yes tvO
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 the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements issuance of a Certificateoff Occup
/>Da% 7
Owner or
Date
SAMUEL CONSTRUCTION
2141 CA.ROBWOOD LN
(4 0 8) 24�--�8�'8 29/—_7100
PERMIT NO.
07040009
PERMIT LSSUE DATE
09/10/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
REMODEL DINING ROOM -RETIREMENT HOME -NON
STRUCTURAL. BEN SAMUEL BL #24634 RENEWED 4/2/07.
Sq. Ft. Floor Area $300000 Valuation
3 2 61512 9 q(i Number Occupancy Type
Issued by
Re -roofs
Type of Roof
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof ,s installed without first obtaining an inspection, I agree to remove
all new n)aterials for inspection.
Signature: of Applicant
Date
All roof coverings to be Class "B" or better