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su DING nrvERTON PERMIT
CONTRACTOR LNFOR'_VIATIC
PERMIT NO 01120043
BURVitDA ssAV
OTKLTMRNIA WATER SERVICE CO
APILA7111SL8fn1
PHONE:
SANITARY NO_ CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERA4IT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRdunderpDECLAofChap
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1 hereb • affirm that i am licensed under provisions of Chapter 9 (commencin
y g
ON DESIGN. CONWffq�� & STEER MONOPOLE
with Section 7000) of Division 3 of the Business and Professions Code. and my license
is in full force and effect.
License Class Lic. 8
Dale Contractor
ARCHITECT'S DECLARATION
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 703 LS, Business and Professions Code: Any city or county
$70000
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
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3 "`3� $B B15a A@da
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Valuation
that he is licensed pursuant to the provisions of the Contractors 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 for a permit subjects the applicant to a civil penalty
of not more than rive hundred dollars (S5oo).
3 0 APN I\ffi& fH ELECTRICAL
Occupancy Type
501 - F I NAL ELECTRICAL
ENERGY
❑ 1, 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,
bub _
Business and Professions Code: The Contractor's License Law does not apply to an
t10RS
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.).
01, as owner of the property, am exclusively contracting with licensed contractors to
c struct 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
Contractors License Law.
❑ 1 am t on Cr S¢. , B & P C for this reason
Own
WORT R'S COMPENSAN D CL 1rATION
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.
❑ I 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 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 Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
1
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCT ION 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 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.
1
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Liabilities, judgments, costs and ez nses which may in any way accrue against said
City in corsJGf this permit.
sD co'S
APP N� N°ILL CO.tvIPLY NTrH ALL N N -P IN
Issued by: D 2z
oc ' S
Signa reofApplic d ontractor a
Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
VYmll 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 IK
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?�"'�N
❑Yes 0
all new materials for inspection. Applicant understands and will comply with
l'
all non -point source regulations.
I have read the hazardous materials requiremenes under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that
if the building does not curie y have a tenant, that i is my responsibility to notify the
occupant of the req ve is hich must be met p r to ' surmce of a Certificate of
Signature of Applicant Date
t
All roof coverings to be Class `B" or better
Owner or authorized agent Date
OFFICE