06070181 7777777777777
-77777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT +C�1�'llEt� G �'iR INERMAZ`IEIN
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
J0p LICENSED CONTRACTOR'S DECLARATION Job Description
t V F I hereby affirm that I am licensed under provisions of Chapter 9(commencing
=z UW with Section 7000)of Division 3 of the Business and Professions Codc,and my license is HOUSE DEMO
rs in full force and effect.
z License Class Lie.x NEEDS To PAY DOUBLE FEES PER GREG.
Date Contractor
o ARCHITECTS DECLARATION
Ct I understand my plans shall be used as public records
�yU
4 Q H Licensed Professional
H1 OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
0 o following reason.(Section 703 1.5,Business and Professions Code:Any city or county
K m which requires a permit to construct,alter,improve,demolish,or repair any structure
o Z} prior w its issuance,also requires the applicant for such permit to file a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 iq.Ft.Floor AreaValuation
J4
t—$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5000
y 5 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 ofN Number Occupancy Type
not more than five hundred dollars(5500). 3 7 5 17 0 0 F V l7
❑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 ns Required Inspections
and Professions Code:The Contractor's 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 We.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 Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am
DECLARATION
1 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 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 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:
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 so as to become subject to the Workers'Compensation
Laws of California.Doe
Applicant
NOTICE TO APPLICA Certificate or Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
[-r rA I hereby affirm that there is a construction lending agency for the performance of
ai > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
z Lender's Address
U C) I certify that I have read this application and state that the above information is
w►" correct.I agree to comply with all city and county ordinances and state laws relating to
rJ U building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
Q. (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA 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 7
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE
Date
HAZARDOUS MATERIALS DISCLOSURE Type of R sof
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(a)? All roofs;;hall be inspected prior to any roofing material being installed.
❑Ycs No
Will the applicant or future building occupant use equipment or devices which
If a roof i:;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes X(No.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
All roof coverings to be Class"B"or better
Owncrofauthorircdagcn` � Date