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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
M
BUILDING ADDRESS:
M I GUEL BEHER
PERMIT NOO 3 0 6 0 0 0 4
19146 TWIG LANE
OWNER'S NAME:
PERMIT LSVb R2/2003
PHONE:. . -
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
'
BLDG ELECT PLUMB MECH
C7 D D D
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 71700) of Division 3 of the Business and Professions Code, and my license is
in•fullforce and effect.
GARAGE/STORAGE
SHED/.ACCESSORIES
License Class Lic. k
Date Contractor
(4 0 0 S Q . FT . )
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 Contractors License Law for the
following reason. (Section 7(131.5, Business and Professions Code: Any city or county
which requires a permit to construct,.altcr, 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
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$3000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy
p y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($5170).
3 7 5 O 8 O 2 2. O O
C11, as owner of the property, or my employees with wages as their sole compensation,
g� Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
101 -
71-2
FOUNDAd
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,
102 —
PIERS
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
103 —
UFER
sale.).
104 —
REBAR
[!] 1, as owner of the property, am exclusively contracting with licensed contractors to
_ 10 5 —
ANCHOR BOLTS
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
106 —
SEWER & WATER
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
LTI
202 —
UNDERFLOOR PLUMBING '
0ON
205—
UNDERFLOOR INSULATION
ereby affirm under penalty of perjury one JAh ollowing declarations:
301 —
ROUGH PLUMBING
❑IhaveandwillmaintainaCertificateofConsenttoself-insumforWorker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
303 —
ROUGH ME CHAN I CAL
❑ 1 have and will maintain Worker's Compensation Insurance, as required by section
3 0 4 —
ROUGH ELECTRICAL
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 are:
305 —
FRAME
Carrier: Policy No.:
306 -
HOLDOWNS
CERTIFICATE OFE FMPTION FROM WORKERS'
COMPENSATION INSURANCE
307 —
INSULATION
(This section need not be completed ifthe permit is forone hundred dollars ($100)
308 —
SHEETROCK
or less')
309 —
EXTERIOR LATH
I certify that in ftperformance of the work for -hicb this permit is isea d, 1 ;hall not
'on
' 310
INTERIOR LATH
employ any r manner so b become su et to the orkcr ore .p
_
LawsofCalio �.
of Exemption, you should
becdme subject to the Worker's Compensation provisions of the Labor Code, you must
5 01 —
FINAL ELECTRICAL ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
502 —
F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
503 —
FINAL MECHANICAL ENERGY
the work for which this permit is issued (See. 3097, civ. c.)
504 —
F I NAL BUILDING ENERGY
Lenders Name
�
,
Lender's Address
505 -
FINAL ELECTRICAL
1 certify that I have read this application and state that the above information is
506 —
GAS TEST
correct. I agree fo 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
FINAL NAL PLUMBING
above-mentioned property for inspection purposes.
O 8
F I N C L
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, ud ments, costs and ex nses which ma in an wa accrue a ainst said Cit
j g 1x r' r r g r
t
I
in consequence of the granting of this permit.
APPLICADa.,UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT
Issued by: 5
NG Date
SOURCE
5_
Re -roofs
Type of Roof
Signal cafApplica ontracto D le
ZARDOUS MATERIALS DISCLOSURE
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)7
'�]
All roofs shall be inspected prior to any roofing material being installed.
E] Yes 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
1 have read the hazardous ma rials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Coda, Sections 25505, 25533 and 25534. [understand that if the building
does no( currcn have atenant that it is my responsibility notify the occupant of the
rcquircmcn ccoraccrtiffc ofOccnpancy.
Signature of Applicant
Date
All roof coverings to be Class "B" or better
Owner oraut orixed ent 1 15atc