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CITE' OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
10482 CHISHOLM AVE
OWNER'S NAME:
PERMIT NO.
FIXATION BUILDERS, INC. 07050202
1295 OLD C
PHONE:
ARCHITECIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business an Professions Code, and my license is
is full facet and cite
License Class Lic. k 39131
DaterJbLJ
ARCH)TEL'I'S
DECLARATION
I understand my plans shall 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 reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, 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 License 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 violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (3500).
p 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 orimproves th-mon, 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_).
p 1, as owner of the properly, art. 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 ovrner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
E]I am exempt under Sec. , B & P C for this mason
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 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 m nsation Insurecarrier and Policy nu b C�
Carrier. e Policy No.: .
CERTIFICATE OF EXEMPTION 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 person in any manner so as to become subject to the Workcrs' Compensation
Laws of California. Date
Appficanl
NOTICE TO APPLICANT: If, after making this CcrtiGcatc 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 domed revoked.
CONSTRUCTION LENDING AGENCY
1 hemhy affirm that there is a eonsu=inn lending agency ror the performance of
the work for which this permit is issued (Sec 3097, Civ, C.)
Lender's Name
Lenders Address
1 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 authori,e mpmsentativcs 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 accmc against said City
in consequence of the g 'ng of is permit.
APPLICAh'r N ERS NDS ND WILL COMPLY WITH ALL NON -POINT
6-19-07 'Q
Signature of ApplicanvC tractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle harardeus material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? zzz,,,nnn'''
El Yes 1� ►+0
Will the applicant or fuulluurc building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes )ao
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHcalth a(ety o Sccti s25505.25533and25534.1undcrstandthazifthc building
docs not cu nil av ten that it is my responsibility to notify the occupant of the
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(650) 5.92-1250
W.0
PERMIT ISSUE DATE
06/14/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
RREMODEL—REPAIR FIRE DAMAGE ROOF FRAMING OVER
GARAGE,ENTRY,FAMILYRM,XITCHEN.
Sq. Ft. Floor Area Valuation
$290000
32641080.1p Number Occupancy Type
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date (r ( Cr
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 rnnf r-nvprnoz to hp CIpQv "R" nr l'—ft—