07010026aOp
m
= z'W
F a
ti—
dao
Cyt.
�p F
�O�
qnqy�
iCC
'coo
rr�u
_Z>
fi=t:
i
CITE' OF CUPERTINO
PERMIT
TINFRMATIQN•
BUILDING DIVISION
BUILDING ADDRESS:
, %>�
.
PERMIT NOs.
� ✓�jfj C�;�
/
OWNER'S AME:
' -
fVY
I/ / ? f
PERMIT ISSUE DATfi
^� j �y
Cl � Cf
r:,uNE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
{ /ALD91
e39G
BUILDING PERMIT INFO
ELECT PLUMB MECH
L_J (�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(10) of Division 3 of the Business and Professisions' Code, and my license is
in full force and eff
� ��
/` n
/ '� /� �' 1211/ Sl�6 /
License Class = Lic. #
/ `� t✓ �
Date Contractor
ARCHITECTS DECLARATION
1 un crsta�{,,-1 my plans s all used as puhli cos
/J _�'�7/ c ` 'S- ��K✓� / / ��/%� ! // %/ / �� /�
/C�/e/se/1 � !/P C mi
Liccns d Professional61 1
DECLARATION
')�
��/,�G/Y, 07/
/ r r`/, CfJ�
i OWNER -BUILDER
I hereby affirm that I am exempt from the Contractors License Law for the
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
prior to its issuance, also requires the applicant for such permit to file a signed statement
9
Sq. Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter
3 Business Professions Code) or
C' ����
(commencing with Section 7000) of Division of the and
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
dollars ($500).
APN Number Occupancy Type
^,
not more than five hundred
t
`
C] 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 docs 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.).
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-
ccnse Law does 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
License Law.
❑ 1 am exempt under Sec B 6t P C for this reason
^.vner Date
WORKER'S COMPENSATION DECLARATION
I 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 Workces 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. 6'% /ir1. &!i 19 Policy No.: A�
CERTIFICATE�'TOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ane hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 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
7 forthwith comply with such provisions or this permit shall be deemed [evoked.
CONSTRUCTION LENDING AGENCY
!2 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.)
aLender's Name
Lender's Address
DI certify that I 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
Jbuilding construction. and hereby authorise representa[ives of this city to enter upon the
for inspection
above-mentioned property purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
in any way accrue against said City
Y3 liabilities, judgments, costs and expenses which may
Z in concc of the granting of this rmit.
/
v
Date
-y APP C UNDERSTANDS WILL COMPLY WITH ALL NON -POINT
SOU LATION�
Issued by:
Re -roofs a j -
Si afore of ApplicanUConr Dare
HAZARDOUS MATERIALS DISCLOSURE
T of Roof
Type
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
^ode. Section 25532(a)?
Yes Ig/t tO
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 dcfr d by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes u
ave ad the hazardous m Is requirements under Chapter 6.95 of the Califor-
25533 and 25534.1 understand that if the building
nia He th & ctyCodc, Sectio SSU '255
does.n t cu ntl a tenant. my responsibility to notify the occupant of the
require c w must be m p' w issuance of a Certifica er ac�cy. Signatul a of Applicant Date
��
Ow cr or authorized agent I are
All roof coverings to be Class "B" or better