06090094BUILDING DIVISION
BUILDING ADDRESS-
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PERMIT NO.
OWNEWS NAME:
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SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with SectionDivision 30(the Business and Professions Code, and my license is
in full (arca andnd of effecec t.
License Class Lic. i!
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Dale Contractor
ARCHITECTS DECLARATION
[understand my plans shall be used as public records
F-� •ed
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Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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{,/i`\J!� Y,�/ i Perm
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following mason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, 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 Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more Ulan five hundred dollars ($500).y.�
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1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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 docs not apply to an owner of
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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 Code:) The Contractor's Li-
ccnsc Law docs 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
icense Law.
1 am exempt under Sec. -, B & P C for this reason
_
Owner � e-3.1
' COMI. A ON RATION
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I hereby affirm under penalty of perjury one of the following declarations:
F1 I have and will maintain a Certificate of Consent to self-insum 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.
Q 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.
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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 ($100)
or Icss.)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ any person io any manner S1 to b ore s It to the Workers' Compensation
Laws
you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
D
CONSTRUCTION LENDING AGENCY
I 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.)
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Lender's Name
Lender's Address
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DI certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize 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
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ry liabilities, judgments, costs and expenses which may in any way accrue against said City
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7 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE
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Re -roofs
Type of Roof
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupamstore or handle hazardous material
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as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
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Code, sector 2ss32(a).
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❑YeNo
All roofs shall be inspected prior to any roofing material being installed.
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 Arca Air Quality Management
all new materials for inspection.
District?
Yes It
❑ No
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safety Code, Secuons 25505, 25533 and 25534. 1 understand that if the building
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docs not currently have a tenant, that it is my responsibility to nodl'y the occupant of the
requirements whi h us' be n' prior to issuance of Certificate of Occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner or au onzc agent Date