06020092 - Permit CITY OF CUPERTINO
BUILDING DIVISION PERMIT
FORMTION•
BUIL1r�G D6ESS: PERMIT NO.
TU��U N PORTAL AVE TBD — TO BE DETERMINED 06020092
OWNER'S NAME: PERMIT ISSUE DATE
CALIFORNIA WATER SERVICE CO 02/06/2007
SANITARY NO. CONTROL NO.
iNE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER:
BLDG ELECT PLUMB MECH
i p a LICENSED CONTRACTOR'S DECLARATION Job Description
U3[= 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
:z with Section 7000)a!Division 3 of the Business and Professions Codc,and my license is 2 400 .SMP ELECTRICAL PANELS FOR BUC KTER PUMP &
a in full force and effect
M z License Class Lic.# WELL P 7MP. SEE NOTES IN NOTEPAD
F,
_,Z Date Contractor
LU.a ARCHITECTS DECLARATION
7 a< I understand my plans shall be used as public records
�qU
U.H Licensed Professional
y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
`< 9 which requires a permit to construct,alter,improve,demolish,or repair any structure
Z} prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
9xin that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $70000
aI- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
L 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 ofNumber Occupancy Type
not more than five hundred dollars($500). 31632057
(
❑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 forsale(Sec.7044,Business Required Inspections
and Professions Code:The Contactors License Law does not apply to an owner of q p
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-
buil will have the burden of proving that he did not build or improve for purpose of
Id u o
rwner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Professions Code:)The Contractors Li.
cense 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 Contractor's
License Law.
❑I am exempt B&P'401r.-I-5/0-7
CJfor is ason
Owner r ' Date ` J5 0-7
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Conscnt to self-insure for Workers Compen-
sation,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 Workers Compensation Insurance,as required by Section
3700 of the tabor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE 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 IQ I to the Workers'Compensation
Lawsor .Califo r. r D 7
Applio f fl f
NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z V) CONSTRUCTION LENDING AGENCY
F" I hereby affirm that there is a construction lending agency for the performance of
p�.7 the work for which this permit is issued(Sec.3097,Civ.C.)
WC1,A Lenders Name
Z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
w i r correct.1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
12�H C11 liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit Date
►- APPLICANT U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued ty:
SOUR S--
rAe0_1 Re-roof s
Signature of Applicant/Contractor Data Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Murd 1 1 Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All root's shall be inspected prior to any roofing material being installed.
❑Yes o
If a roo 7 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 incd by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cotte,Sections 25505.25533 and 25534.1 understand that if the building
does not currently h a ant.that it is my responsibility to notify the occupant of the
reyuiremonts m t prior to issuance nra certiriatco0 S D? Signatu e of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorize agent Dare