06120091 CITY OF CUPERTINO
BUILDING DIVISION
PERMIT � TRl �1R j� RMATI®N'
«.
BUILDING ADDRESS: PERMIT NO.
21267
OWNER'S NAME: PERMIT L95UEDATE
UNA MAS 21267 STEVENS CREEK BLVD 01/22/2007
,)NE: __V_5 n SANITARY SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
j o p LICENSED CONTRACTOR'S DECLARATION Job Description
4 m F I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z with Section 7000)of 'sion 3 of the Business and Professions Code and my license is REV I S I C[v—SOFFIT DETAIL
y in full force and cffec
j Z License Cl Lic.M it
3 f„p Date Contractor c e" `
UJ ARCHrrECrS DECLARATION
N< 1 u.[
.J .J
n crstan in
plans shall be used as public records
gyri
` y Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
{i which requires a permit to construct.alter,improve,demolish,or repair any structure
n Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area 0
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)ur
y 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 32627035 . $N Number Occupancy Type
not more than five hundred dollars(5500).
❑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 Required Inspections
and Professions Code:The Contractor's License Law docs 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-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑I,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 pmjects with a contractors)licensed pursuant to the Contractors
License Law.
C31 am exempt under Sec B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑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.
❑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 Worke s Compensation Insurance carrier and Policy number
,16
Cartier. - Policy No.:
CERTIFICATE OF EXEMP 7ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I ceniCy 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z — CONSTRUCTION LENDING AGENCY
01)
E-r 4 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.)
QLender's Name
Z Lenders Address
U C I certify that 1 have read this application and state that the above information is
f3. " correct.I agree to comply with all city and cotmty ordinances and state laws relating to
rJ V building construction.and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U z �in co ucncc the' nung of this permit.PPL ANT D TANDS AND WILL COMPLY WI ALL NON-POINT Issued b l: Date 2ZOU E RE LA NS.
Re-roof:
Signature ofAcankContracwr Dare Type of Zoof
AZARDOUS MATERIALS DISCLOS RE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munic' 1 Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof.,;shall be inspected prior to any roofing material being installed.
❑Yes 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 contaminantsas/dined by the Bay Area Air Quality Management all new 1 naterials for inspection.
District?
❑Yes o
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety ode,Se tions 25505,25533 and 25534.1 understand that if the building
docs no currently ave nt,that it is my responsibility to notify the occupant of the
mquirc encs whi m t prior to issuance of a Certificate Oc Signatur-,of Applicant Date
I ° r All roof coverings to be Class"B"or better
Owner or authori-rcd-64 Date