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CITY OF CUPERTINO
BUILDING DIVISION PERMI
BUILDING ADDRESS:
PERMIT NO.
11723 DOROTHY ANNE WY
CRAFTSMENS GUILD INC
07010073
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PHONE:
SANITARY NO. CONTROL NO.
(408)366-1000
ARCHTTECTIENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000)ofDivision3oftheBusinessandProfessions Codc.andmylicense is
1400' REMODEL-ELECT/MECH, LIVING RM, FAMILY RM,
in full force and effect. Z ,�
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License Class Llc p �
��—Contractor.
CONVERT LIVING RM TO MASTER BEDRM-REMOVE STAIRSM
Date
ARCHrrECPSDECLARATION
BEAMS & SHEARWALL, REPLACE WINDOWS & GARAGE DOOR.
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, impmve, demolish, or repair any structure
! prior to its issuance, also requires the applicant for such permit to file a signed statement
is licensed the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he pursuant to the provisions of
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
$ 5 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
Section 7031.5 by any applicant for a permit subims the applicant to a civil penalty of
not more than fire hundred dollars (s500).
36654125.w
C] 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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will do the work, and the structure is not intended or offered forsale (Sec.7044, Business
and Professions Code: The Contractor's License Law does 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 or
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 contractor(s) licensed pursuant to the Contractors
,.. .. ..
License Law.
❑ I am exempt under Sec• , B & P C for this reason
Owner Date
-
WORKER'SCOMPENSATIONDECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to seif-insum for Workers Compen-
...... _... .
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
- - -
work for which this permit is issued.
.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
'
My Workers Compensation Insurance carrier and Policy number arc'
5 � -r%N 17 �
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars (EI00)
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 Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constnrctinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
7 Lender's Address
I certify that 1 have read this application and state that the above information is
-' correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorise representatives of this city to enter upon the
above -mentioned propenyfor inspection purposes.
yr (We) agree to save, indemnify and keep harmless the City of Cupertino against
n liabilities, judgments, costs and expenses which may in any way accrue againstsaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS A PLY WITH ALL NON -POINT
Issued by: Date
SOURCE REG q �
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/"1 fa
Re,roofs
Type of Roof
Signa�fA, ppiican onuactor Date
Will the applicant or future building occupantstom or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)? ��
Yes t*!'r'r
All roofs shall be inspected prior to any roofing material being installed.
❑ o
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 hazardnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
C] Yes (Syrvo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534. I understand that if the building
Jots not curren0y have a tenant. that it is my responsibility to notify the occupant of the
requircmcns which must be met p' t uancc of a Ccniricatc o(occupan�/
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or authorized ¢ 0 Cn