03120039CITY OF CYJFEI2TIN0
t�/
BUILDING DIVISION PERIV.
BUILDING ADDRESS:
PERMIT N0.
03120039
10
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
'
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of vision 3 of the Business and rofessiuns Code, and my license is
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TERMITE REPAIRS -
CONTRACTOR: DYNAMIC BUILDERING ASSOC.
1��/�Contrac��J�
ARCHI EC 'S D�.
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or 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
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter9
Sq. Ft. Floor Area
Valuation
(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
ApN Number
Occupancy
Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than rive hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
3 0 4 0 . 00 Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business4
and Professions Code: The Contractor's License Law docs not apply to an 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 Li.
,
cense Law docs not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contraclor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain aCcaifrcateofConsent toself-insure for Worker'sCompcn.
sation, as provided for by Section 37110 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37110 of the Labor Code, for the performance of the work for which this permit is issued.
My
OF.XEMPTIO OM WORKERS'
COMPENSATION INSURANCE
,
(This section need not be completed if the permit is for one hundred dollars (SIOD)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certirucate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
Lender's Address
I I certify that 1 have read this application and state that the above information is
cored I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(Wc agree to save, inde iFy and keep hornless the City of Cupertino against
j liabil; ies,j co and nscs which may in anyway accrue against said Cily
e o th,
in c n qu n c of th gating f t is permi .
' AP LI D S N S D LL COMPLY WITH ALL NO, -PdINT
s
Issued by: Date
/
Re-roofsl
Type of Roof
i naw of p IEA t/Contra for r Da(c
\ HAZARDOUS MAT RIALS DISCLOSURE
i c Oglicant or future building occupant Store or handle hazardous material
as defined by the Cupertino M picipal Code, Chapter 9.12, and the Health and Safety
zss3z(a)? f
cmde,Ycs
All roofs shall be inspected prior to any roofing material being installed.
0 Ycs 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 Arca Air Quality Management
all new materials for Inspection.
District?
❑Yes
Ihavcrcad ha�ardmisV Is requirements under Chapter 6.95ofthe Califor-
niaHcalth& y, dc, cGns,25$33and25534.1understandthatifthe building
does mol c e Oy h 44m��q teat, n(yIponsibility to noGl'y the Occup t of the
require awerOceupan'e
Signature of Applicant Date
All roof coverings to be Class "B" or better
'0 ncr ter authorirc�agcnt — f ✓ arc