09060112 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
19014 rPTT,.qnT\T AVE H ,N CONSTRUCTToN
OWNER'S NAME: PERMIT ISSUE DATE
PHO A 9 9 CONTROL NO.
408 888-2898
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a 0 o a
u o p LICENSED CONTRACTOR'S DECLARATION
U)= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Md with Section 70(10)of Division 3 of the Business and Professions Code,and my license is
=y in full force and effect 1�! RMDL BATHRMS & KITCHEN(135SQ) ;NORE—RF& NO
Z License CI s tic.ff
-in Date STRUCTF L
ARCHITECTS DECLARATION
a
U 1 understand my plans shall be used as public records
Jw
c y Licensed Professional
n n 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
LOO following reason.(Section 7031.5,Business and Professions Code:Any city or county
R 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 L acne Law(Chapter 9 Sq.Ft.Floor Area Valuation
nt-a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of $8000
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500)
0 1,as owner of the property,or my employees with wages as their sole compensation, 3 7 5 0 9 0 C 8 . 00
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 docs not apply to an owner of Required Inspections
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractoes Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractors)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I 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-
on,as provided for by Section 3700 of the Labor Code,for the performance of the
ork for which this permit is issued.
0 1 have and will maintain Workces Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance prier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need trot be completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any maancr so astabccomc subject o the Workers'Co pc
Laws of California.Date�G -�
Applicant - -
NOTICE TO APPLICANT:If,after making this Certificate of Excmpiion,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z 2 CONSTRUCTION LENDING AGENCY
E-e►�.n 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.)
QL.endets Name
Z:)
z Lenders Address
U Q 1 certify that I have read this application and state that the above information is
(y►" corecL 1 agree to comply with all city and county ordinances and state laws relating to
Obuilding construction,and hereby authorim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
H to liabilities,judgments,toss and expenses which may in any way scenic against said City
U Z in consequence of the granting of this permit
m't APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S4��(&wDate
SOURCE REGULATIONS.
Re-roofs
Signature of Applicant/Cogifictor Dfitc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes KN.
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
-mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new IT aterials for inspection.
trict?
0 Yes ON.
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 which must be met prior to issuance of a Certificate of a pan . Signature of Applicant Date
Owner or autharizcd agent Datc
All roof coverings to be Class'J `'or better