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07020101 CITE'OF CUPERTINO BUILDING DIVISION PERMIT � tGT©R ZI�QRMATI�N' PERMIT NO. BUILDING ADDRESS: 21877 SHATTUCK DR TBD — To BE DETERMINED 07020101 PERMISSUE DATE NAME: IT 2/21 /2007 L,I NG T S ENG SANITARY NO. CONTROL NO. P. !E: BUILDING PERMIT INFO ARCHITECUENGINEER: BLDG ELECT PLUMB MECH a Zo LICENSED CONTRACTOR'S DECLARATION Job Description V I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is KITCHEN & MASTER BATHROOM REMODEL. t=y in full force and effect. Z License Class Lle•n NON STR JCTURAL o Date Contractor t ARCHITECTS DECLARATION j a< 1 understand my plans shall be used as public records SW U ' U.� Licensed Professional H c OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the COOfollowing 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 "H prior W its issuance,also requires the applicant for such permit to file a signed statement Sq,Ft.Floor Area Valuation ?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 $35000 ti rc (commencing with Section 7000)of Division 3 of the Business and Professions Code)or i that he is exempt therefrom and the basis for the alleged exemption.Any violation of ,�1 Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 5 614 0 0 4V not more than five hundred dollars(5500). 0 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,Business Required Inspections and Professions Code:The Contractor's License Law does 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.). �prr 1,as owner of the property,am exclusively contracting with licensed contractors to itonstruct the project(Sec.7044.Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves dtemon,and who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's iCense Law. I am exempt under See _ ,B&P C for this reason Date V WOR 'S MPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 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.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(S 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 so 'ct Compensation Laws of Californ.3—Date Applicant - NOTICE TO APPLICA a �Wsr ertificate of Exemption,you should become subject to the orker' ompenisions of the Labor Code,you must Oforthwith comply with such p visions t shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of pC.7 the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name jLender's Address U 0 1 certify that I have read this application and state that the above information is Lt+ correct.I agree to comply with all city and county ordinances and state laws relating to J building construction,and hereby authorim representatives of this city to enter upon the ahove-mentioned property for inspection purposes. +� (We)agree to save,indemnify and keep harmless the City of Cupertino against ,Ft rA liabilities,judgments,costs and expenses which may in anyway accrue against said City U Z in consequence of the granting of this permit. Date ►'� APPLICANT UNDER ANDS ANS WILL COMPLY WITH ALL NON-POINT Issued b y: G SOURCE REGULATT Re-roof: Signature of A c nuactor Usti Type of Roof AZARDOUS MATERIALS DISCLOSURE yP Will the applicant or future building occupant store or handle hazardous material <defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety lc,Section 25532(a)? All roof 3 shall be inspected prior to any roofing material being installed. 0 Yes t 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 Area Air Quality Management all new Materials for inspection. District? Cl Yes �No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Hcalth&Safcty Codc,Sections 25505.25533 and 25534.1 understand that if the building does not currently have a tenant,that it is my responsibility to notify the occupant of the Date requirement%which m e issuance of a Certificate of Occupancy S ignatul e of Applicant All roof coverings to be Class"B"or better Owner or au c e t Date'