08090040rrrrV OF C1C 1JPF.RTINn —T—
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
21837 TERRACE DR
OWNER'S NAME:
ARCH TFCT/ENGINEER
o p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
t Z< le le in full force and effect
j , Z License Class Lie err
i Date Contractor
ARCHITECT'S DECLARATION
i I understand ray ARCHITECTS
shall be used as public records
�aU
' o Ucmxd Professional
t y OWNER -BUILDER DECLARATION
i I hereby affirm that I am exampt from the Contractor's License Law for the
00 following reason. (Section 1031.5, Business and Professions Code: Any city or county
S V which requires a permit to cronatnrcL alter, improve, demolish, or repair any structure
prior io its issuance- also requires the applicant for such permit to file a signed statement
z�
� that he is licensed ptrsoant o the provisions of the Conlactor'a License Law (Chapter 9
$ (commencing with Scction 7000) of Division 3 of the Businessand Professions Code) or
that be is exempt therefrom and the basis for the alleged exemption Any violation or
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ L n 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 tale (Sec. 7044, Business
and Professions Code: The Contractor's Liaum law does Dot apply to an owner of
property who build& 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. I,
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
C
831) 818-0072
' 11 14. h,
PERMIT NO.
PERMIT ISSUE DAIS
A O. CONTROL NO.
BUILDING PERMIT INFO
BL.DG ELECT PLUMB MECH
Job Description
ADDING 2ND STORY-799' 2 BDRMS/1 BATHRM & STAIRS.
Sq. Ft. Floor Area
75000
Valuation
APN Number I Occupancy Type
35617020.00
Required Inspections
Al. u owner of the property, am taclusivefy contracting with licensed contractors to
construct the Project (Sex. 7044,1hudru s and Professions Code:) The Contractors U-
ccnse Law does not apply m an owner of property who builds or improves thereon, and,
Who contracts for such projects with a contractor(s) licensed pursuant to the Contrames
License Law.
❑ lam Sec. B& P C for is n
Owns
hereby afrtrm under penalty of perjury Pry of the following declarations
7-31.'0
I hx+ and will maintain a Ccniliate of Consent o self -insure for Workers Cum pcn-
as provided for by Section 3700 of the Labor Code, for the performance of the
k for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as required by Section
of the Labor Cede, for the performance of the wok for which this permit Is Issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMFI70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S I0G)
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 u brxa c subject to m Workers' Compenadon
Laws of Cal
Appllwrt if 'L D —
NOTICE TO APPLICANT. 9( of m dug U(i of Exemption, you should
become subject to the Workers Compensation RoWnions of the Labor Code, you must
O forthwith comply with such provisions or this petTit shall be deemed revoked.
f% CONSTRUCTION LENDING AGENCY
t--d 1 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.)
M Lenders Name
Z Lender's Address
I certify That I have read this application and state that the above infonmation is
^-' correct. I agree -to comply with all city and county ordinances and state laws relating to
Jbuilding construction, and hereby authorim representatives of this city to enter upon the
jabove -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep humless the City of Cupertino against
n liabilities. judgments, costs and expenses which may in any way accrue against said City
in consegtr_acc of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT Issued by:
cur usr�r ern.rc .•r.nr.rc /7 1
Signature
HAZARDOUS MA DISCLOSURE
Will the applicant or future bull ' pant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
Yes X.
Will the applicant or Putter building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Disuict7
Q Yeso
i have read the hazardores materials requirements undcrChaptcr&95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does
of Applicant
Date
All roof coverings to be Class'%" or better