277094PPLICANT TO FILL IN INFORMATION WITHIN RED LII
CITY OF CUPERTINO
BUILDING DIVISION APPLICATION/PERMIT
LICENSED CONTRACT'OR'S DECLARATION
Iherebyoffino that l amlicensed undapmvisionsofChapteomm
r9(cencingwim
00 Senion]BOB) f no eBusiness and Professions Code,mdmylic raisin
TLZF allfnmeondeff�,
GG x� Li,cnsc Cly.s Lia.«
y<y Dat •' Conwcmr �� r s•enT�R I W O
Zoo, ARCHITECTS DECLARATION g C..
2
O o o, 1 understand my plans shag be must u public records.
FNFcy
�Y � J Licensed Pmfessianal
Wm< OWNER.BUILDER DECLARATION
04F I hereby afrom tom 1 am exempt from the Contractor's License Law for the
sir
Ow following mason. (Section 0031.5, Business and Professions Code: Any city m county,
5 which requires a pemnit to conamm, alter, improve, demolish, nr repair any swnum
;!tY�
prior o its issuance, also requires me applicam for such Permit o file a signed statement
that he is licensed pursuant to the provisions of the Communes License Law (Chapter
d a�' 9(commencing with Section 7")of Division 3 of the Business end Professions Code)
_,o, m that he is exempt therefrom and the buisfor me alleged exemption. Any violation of
3Q Section 7031.5 by any vp,Ilcwa far a permit Subjects the oppbcantto a civil penalty of
not more mon five hundred dollars (450).
m CII,unwncroftheproperty,mmyemployeuwim wagesu meirsole compensation,
x,322 will do the work, and the Swcture is not intended or offered for Sale (Sec. 004q Business
and Professions Code: The Cannot Liceme law does no apply to an owner of
prolixity whn builds or improves thereon, and who does such work himsel for through his
own employees, pm v ided that such improvements am not i mended conducted for We. If.
however, the building or improvement is sold within one yea of completion, the owner -
builder will Lave 11a burden of proving that he did not huild or improve I'or purpou of
sale.).
❑ I, as owner of the propeny, am excl mively contracting with licenced convectors to
corm uct the project (Sec. 7044, Business and Professions Code:) The Contractor's
LiuLawdonsnofapplymsitownerofpropmywhobuildamimprovesmer ,end
who cnntrams forsnch projects with a connecmr(s) licensed pursuant m the Conuvn&S
License Law.
❑ l am exempt under Sec. , B & P C for this reason
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a modicum of comm in u1f-insure, or a imbricate of
Wookers' Compensation Insurance into certified copy thereof (Sec. 380, Lab C.) which
covers all oro se'syydc th' pelf.
Policy«
company
❑ Certified copy is hereby famished.
❑ Certified copy is filed with the city inspection division.
CERTIFICATE OF IiXEh1PTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nm be completed if the permit is fmone hundreddollars (510)
or less.)
I certify that in the performance of me work for which this permit is luued, I shall
not employ any permit in any marrow so as to heorme subject to the Workers'
z Cma,mmion Lawsof Califmnia. Date
Applicant
z 0 NOTICE TO APPLICAW:If,after making IMS Cenificate of Exemption, you Should
) become subjecuo the Worker's Compensation provisions of me Labor Cdm
e, you ust
�7;