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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
10239 RICHWO D DR
TBD - TO BE DETERMINED
OWNER'S NAME:
PERMTf ISSUE DATE
:
BUILDING PERMIT INFO
-ELECT
BLDG PLUMB - MECH
0 0 0 0
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm tint 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 force and effect
ENLARG BTHRM & ADD A WALL (16 SQ)
License Class Lic. M
f
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby affirm that I am exempt from the Contractofs 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
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 Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
6 5 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70315 by any applicant for a permit subjects the applicant to a Civil penalty of
not more than five hundred dollars (S500}
36908044.00
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required red Inspections
etractor's
win do the work, and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Code: The ConLicense Law does not apply to an owner of
q p
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,).
a'f,/as owner of the property, am exclusively eonuuting with licensed contractors to
corstmct 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 contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt
hemby 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 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 arc:
Carrier. 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, i shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of CaGfprryp. ate
Applicant Ui�i
NOTICE P . If, a0er making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, your 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 (See. 3097, Civ. C.)
Lender's Name
Lemices 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 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
Issued by:
HAZARDOUS MATERIALS DISCLOSURE
VAR 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 Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
[3 Yes El NO
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 hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter6.95 of cite Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534. I understand what if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requirements