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CITY INO
ncnnISION PERMgT
CONTRACTOR INF6RMTION:
WILLIAM A HURT 4
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B(j�LpuS',G4DRF,Sg; C#ZAR AVE
PERMIT NO.
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02040129
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2131 AMERST ST.
APff`YY/Y67`62
PHONE:
(650)255-1802
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUN4B MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
DEMO
with Section 7000) of Division 3 of the Business and Professions Code, and my license
is in full force and effect.
License Class Lic. #
Date Contractor
ARCHITECT'S 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 Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
$9000
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
3 i.�. F4 (�R36r.f!�1'�a -
Valuation
that he is,licensed pursuant to the provisions of the Contravor'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',a permit subjects the applicant to a civil penalty
five of not more thanve hundred dollars ($500).
NO AqS&RMIID INSPECTIONS
Occupancy Type
❑ 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
- -
Required Inspections
owner of 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 Contractor's
License 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
Contractor's License Law.
❑ I am exempt under,Sec., B & P C for this reason
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WOR'trS COMP ATIO ECLA7rRATION
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 Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
❑ 1 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 Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
-
CERTIFICATION 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 pe rmance the work for which this permit is issued, I
shall note p{o)i�any perso t an ma er so as Y5ec p.gubiCc[ toethe Workers'
�->
Compensat
Certificate of Exemption, you should
come'subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perfortnance
of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's 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 nd expenses which may in any way accrue against said
City in consequence of the ting of this permit.
CL
APPLICA
Date
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
Type of Roof
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
°Yes No
All roofs shall be inspected prior to any roofing material being installed. _.
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 contaminants as defined by the Bay Area Air Quality Management
District?
all new materials for inspection. Applicant understands and will comply with
C1 Yes
all non -point source regulations.
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not curt tly have a tenant. that it is my responsibility to notify the
occupant a require t which must met prior to issuance of a Certificate of
Occupancy. i�
Signature of Applicant Date
All roof coverings to be Class "B" or better
Ow r authorized agent Date
OFFICE