08040010CITY OF CUPERTINOsr
DIVISION
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BUILDING PERNIITPERMrr
'INC
BUIf.DTg�t "� IA VENTURA #23
HANKINS CONSTRUCTION
NO.
08040010
OWNER'S NAME:
PERMIT ISSUE DATE
SA?QTARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
ADD 5 ' 0 "X8 ' 0 " HNDICP RMP&
BLDG - BE�LECtT
PLUM M13CH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Sector 7000) Divisors 3 of the Business sad Professions m is
in f ect !n full forte sellecect
Livens Lic. 0
Date Contractor
DELI ARATION
understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following tssson. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to concoct, 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 Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70DO) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exmrptioa Any violation of
APN Number
QCCu
Occupancy Type
Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty of
not mere thin five hundred dollars (ZWO
❑ 1. as owner of the property, or my employees with wages its their sole compensation,
will do the wort, and the structure is not intended or offered for sale (Sec. 7044, B usiness
Required Inspections
and Professions code Tbc Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who doessuch wort 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
tale).
❑ L as owner of the property, am exclusively contracting with licensed contiacm to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U.
cease Law don not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conlractor(s) licensed pursuant to the Conractors
Lsc=w Law.
❑ I am exempt under Sec , B k P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaratoac
❑ I have and well maintain a CertlGcste of Consent to self -Insure for Worker's Compea-
station, as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is issued.
❑ I have and will maintain WorVsts Compensation Insurance, as required by section
370D of the Labor Code, for the performance of Oil wort for which this permit Is issued.
My Wo C in ensation Insurance er and Polity number
Corti Polity No-: M
CERTIRCP.TE 0 CEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olds section need not be completed If the permit is for one hundred dollars (S 100)
or less.)
1 unify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any man= so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after mating this Ccrtifhcate of Ezcmption, you should
become subject to the Work= 3 Compeosation provisions of the Labor Code, you m=
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the wort for which this permit is issued (Sec. 3097, Civ. C-)
Lenders Name
Lenders Address
'
I eenify that I have read Lids application and state that the above information is
cortccL 1 agree to comply with all city and county ordinaries and sine laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purpose
.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. judgments, costs and expeases which may In any way accrue against said City
in co f the granting of this permit
APPLICA UNDERSTANDS AND W COMPLY WITH ALL N N-PO
Issued by: Date
SOUR Ti0
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applicant or future bull g occupant store or handle hamrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section [:]
❑ Yn f�No
All roofs shall be inspected prior to any roofing material being installed,
Will
ins
a roof is installed Without first obtaining an inspection, I agree to remove
the applicant or future building occupantaoccupantIf
emiL hazardous air conuaminams as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes 1'fNo
1 hoc read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Head Lh h Safety Code, Sections 25505 25533 and 25534.1 understand that If the building
edoca shot a rman4 that' a my responsibility ta rrotify the pant the
�nlawh
require m m