06080121 CITY OF CUPERTINO p
BUILDING DIVISION PERMIT � 'j`R
BUILDING ADDRESS: PERMIT NO.
21091 TULITA CT TBD — TO BE DETERMINED 06080121
OWNER'S NAME: PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION O
V E= I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z U with Section 7000 of Division 3 of the Business and Professions Code,and m license is ,
�+ ) y y NEW SFLWL 4545 GARAGE 700 '
?�H in full force and effect
? Lice CI Lic.0
D.-) Contractor
• ARCHITECTS DECLA O
7 < I understand my plans shall be used as public records
)aU
H Licensed Profcssional
y OWNER-BUILDER DECLARATION
a I hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following 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
J Z In prior to its issuance,also requires the applicant for such permit to file a signed statement
`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
Q t $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $1013777
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 of Number Occu anC T e
not more than rive hundred dollars(M). 3 2 6 2 8 0 6 9 `IP p y yp
❑I,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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions :)The Contractor's Li-
cense Law does not apply to an owner of property who bu'ds or roves thereon,and.
who c tracts for suc4NSATION
tractor(s)license pursuant Contractor's
Licer�
❑I arum de .B&P.0 for_' reason
Owner .. Date
WDECLARATIONI hereby affirerjury one of the following declatations
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the tabor Code,for the performance of the
work for which this permit is issued.
. irI 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 W s Compenotation Insurartc airier and Policy number ate: �j)_
Cartier.
Policy No.:",�` k 13
CERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed 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
O forthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
F+►-+ 1 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.)
CW A Lender's Name
a z Lender's Address
U 0 I certify that I have read this application and state that the above information is
(L s correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W ahove-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
,Fy to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence f the granting of this permit.
APPLICA%ONDTERSI;%NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DateSOURCE � �• l�V.��
Re-roofs
Signature of Applicant/Comractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(9)?
❑Yes ^No 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 contamin as defined by the Bay Area Air Quality Management all new maerials for inspection.
District?
❑Yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not current occupant a ten at it is my responsibility to notify the oupant of the
requirements w c of a Certificate of Occupancy. Signature()fApplicant Date
,,go . a
Owncrorauth 'rcdagcnt Date All roof coverings to be Class"B"or better