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CITY OF CUFF,RTINO
BUILDING DIVISION PERMIT
CONTRAC LOR INh}ORMATION
nu LDING ADDRESS:
561 (-TTT,RFRT_SQN DR
HELEN & CADIR SARLI
PERMITNo04040145
ER'S NAME:
PERMIT ISSUE DATE
HELEN & CAD
4
ONE:
SANITARY NO. CONTROL NO.
ARCHITEC-PENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB
MECII
CJ 0
0
DECLARATION
LICENSED COKnsed TORorder
Job Description
1 hcrchy (form that i am licensed under provisions ors
t 9 (mmmense
p
is
of Division 3 of the Business and Professions Cole, and my license is
with Section Code,
Cf
Licenseforce and ,rrea
REPLACE CEIL. JOIST IN GARAGE
License Class Lic.p
Class
./WALL
Date Conlomm,
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby aform that 1 am exempt from the Conoactors License Law for the
following reason. (Section 7131.5, Business and Professions Code: Any city or county
which requires a pennit to construct, alter, impmvc, demolish, or repair any structure
poor In its issuance, also requires the applicant for such permit to rile a signed sotument
that he is licensed pursuant o the previsions Of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 7100) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant u a civil penalty Of
37EPN ` ffi*cr00
Occupancy Type
P Y
nor mom man live hundred dollars (SSW).
YP
as
1, as owner of tiro pmperty,n my employee with wages their sole compensation,
I do , work. and hsbm or offered for sale (Site. 7W, Business
h e unc is not fm irked
and Professions Code: The Contractors License Law docs not apply to an owner of
Required Inspections
his
property who s. pro or improvesch rcon, and who does such work himself oor ffered
Own employees. dedfm ole.r.
ear
I
prvehimps sold witarcnot
however, the building or impm ofdmleaxd
the building or ns sold within one year of completion, he owe
will have the burden of proving mat W did not Wild or improve for purpose of
proving or
sale.).
.Is.).f
'/•y/"/Z7
0 Lax owner of property, exclusively contracting with to
project
mwct Mees joapplyto0f4,wnerossand :) The Contractor's
. B CWeUTM1Coasthemod,
nt, who
cane law does not apply m u owner of properly who sed p or improves menton, and
dd
whocontractsLac6 for such pmjccu with a contnaor(s) licensed pursuant m he Contractor's
License Law.
❑lam exempt under See. ,B&PCfor this reason
/
r
IlClpq S�Y�I DamN4•-2f,oA
WORKER'S COMPENSATION DECLARATION
0' /
I hereby affirm under penally of perjury one of the following declarations:
/Y
I have and will mai main a Cmificale of Consent to self -insure for Worker's Comp,m
amion, as provided for by Section 3900 of the labor Code, for the performance of the
work for which his permit is issued
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37W of he Ube, Cole, for he performance of he work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy NO, _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need mol W cemFlemd if thc permit is forme hundred dollars (51(811
,it max.)
1 certify that in the performance or the work for which this permit is ixsucd, l shall not
employ any person in any manner so as in become eubjecuo the Workers Compensation
Laws or California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenifesm of Exemption, you should
become subject to the Worker's Com pensmion previsions of the tabor Code, you must
forthwith Comply with such provision or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm hat here as ronamction lending agency Butte performance of
he work for which this permit is issued (Sec. 3V)7, Civ. C.)
Under's Name
Landm's Address
1 eer ify hal 1 have mad his application and sum that Be above information is
colica. l agree to comply with all city and county ordinances and sort laws relating to
'
building conswnion, and hereby authorize representatives of Nis city to enter upon Be
above-mentioned properly for inspection purposes.
(We) agree tp save, indcmni fy and keep harmless the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way accrue, against said City
in cometrence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POhYT
Issued by: Date
SOURCE REGULATIONS.
A�
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