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CITY OF CUPERTINO
BUILDING DIVISION PERMIT > Cfi1T�ATflR.I� I .
BUI I RESS: PERMIT NO.
81 MANN DR TBD — TO BE DETERMINED 08020109
OWNER'S NAME: PERMIT ISSUE DATE
LAI JACK K AND GLORIA H 06/02/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Q O a LICENSED CONTRACTOR'S DECLARATION
V
P I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z w with Section 7000)of Division 7 of die Business and Professions Code,and my license is NEW INLAW UNI T—7 8 4 S Q, 2 4 S Q PORCH, 5 4 8 S Q ATTACHED
a- in full force and effect
License class Lie.a GARAGE.
F p Date Contractor
ARCHn`ECTS DECLARATION
1 understand my plans shall be used as public records
1yU
a Licensed Professional
n y
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Conuactoes License Law for the
D O following mason.(Section 7071.5,Business and Professions Code:Any city or county
e m which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permil Lo rile a signed statement
E=G that he is licensed pursuant to the provisions of the Comracwr's Uccnse Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt— (commencing with Section 7000)of Division 7 of the Busincss and Professions Code)or $160000
y .. that he it exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 2 645 010 . Number Occupancy Type
not more than rive hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and tire structure is not intended or offered for sale(Sec.7044,Business
and Professions Code The Contractors License Law does net 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,dee 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 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 exI'u to ,B&P�or s reason
Owner ate 0
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 7700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurance,as required by Section
7700 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. Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars($100)
or less)
I certify that in the performance of the work for which this permit it issued,1 shall not
employ any person in any manner so w me bJje to the Workers'Compensation
Laws of California Date
Applicant
NOTICE TO APPLICANT:If,after making this Certifica Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,JZ forthwith comply with such provisions or this permit shall be deemed revoked.
z O
CONSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a construction lending agency for the performance of
Ix 7 the work for which this permit is issued(See.7097,Civ.C)
aQ Lender's Name
Z Lenders Address
U Q I certify that I have read this application and state that the above information is
coned I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
>414
(We)agree to save,indemnify and keep harmless the City of Cupertino against
e0) liabilities,judgments,costa and expenses which may in any way accrue against said City
V Z to consequence of the granting of this permit
►- APPLICANT UNDE NDS AN914%L COMPLY WITH L NON-POINT Issued by: Date •2 z�
SOURCE REGULA ONS. c�
y\`� luvr— Re-roofs —moi
Signature of Applicam/Cantractor Date
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 Safely
Code,Section 25572(a)? No All roofs shall be inspected prior to any roofing material being installed.
❑Yes
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
emit hazardous air contamipams as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes i
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safely Code,Sections 25505.25537 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
require hich mass be mel brto issuance era certificate of Occltpan . Signature of Applicant Date
All roof coverings to be Class'J "or better
Owner or fulho&cd agNL Date
CITY OF CUPERTINO
NEW SII�TGLE/li�IULTI FAMILY DWELLING
CUPEkTINO PERMIT APPLICATION FORM .
APN#�� Date:
Building Address:
1 C4 c10 A f D R Fs T/ u
Mailing Address (if different from building address):
Owner's.Name: Phone#:
Contractor: Phone moi-:
Fax#:
Contractor License#:
Cupertino Business License#:
Contact: Phone#: 4023 .�;74-gg
6--LL3+ 410
B.
Fax#: Ar n 36 �oS
Alternate Contact: Phone#:
Fax 4:
Single-Story Two-Story ❑ Three-Story ❑ Basement ❑ Hillside
Multi-family ❑ Apartment ❑. Condo ❑ Townhouse ❑
Sq.Ft. Living Area(Including Basement &Attached Garage: Sq.Ft. Garage (Detached Only):
Valuation: 3� /
Job Description:
/AJ - L-AAv
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11F ❑ 11, 111, V-lHR ❑ 11, 111, 1V V-N '� v
Project Size: Standard Large❑ Major❑
Green Building: Must attach completed Green Building Checklist to the plans
Green Building Points Achieved:
For help, contact Build it Green at www,.huildit6reea�.or�