07010171 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C1NT ,GC1R I1FUgZMATIQN
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: TE
fitKLEIN BERNARD AND PAULA P 360 MEMORIAL DR STE 140 01/29/2007
rFnTTc• SANITARY NO. CONTROL NO.
(866) 293-3031
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
40 zp LICENSED CONTRACTOR'S DECLARATION O O
W Ei I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
=z with Section 7000)of Division 3 of the Business and Professions Code,and m iccnsc is REPLACE WATER HEATER 5 0 GAL GAS
M y in full force and eIf t. z
? License Class Lic.N
3 f DateContractor
R ITEC-S DECLARATION
U 1 understand my plans shall be used as public records
0
G y Licensed Professional
n y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
in O 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
y Z y prior to its issuance,also requires the applicant for such permit to rile a signed statement
EC that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q.Ft.Floor Area Valuation
Y F (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or $500
a. that he is exempt therefrom and the basis for the alleged exemption.Any violation of Q jj�� ane
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of 3 6 6 5 2 0 7 3 .ZJtJN Number Occupancy
not more than five hundred dollars(5500). P Y Type
❑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 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 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 Commuies 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 Contractor's
License law.
❑I 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 Work s ompensation Insu nee cam olicy number am:Carrier u-� icy 10o.:VZ—5!92
We
CERTI CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S I00)
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 Workcrs'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
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
z� CONSTRUCTION LENDING AGENCY
Er 1 hereby affirm that there is a construction lending agency for the performance of
LY the work for which this permit is issued(Sec.3097,Civ.C.)
WG1.Q Lender's Name
a z Lcndees Address
U Q I certify that I have read this application and state that the above information is
Lt. ►" correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(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
V Z in consequence of the granting of this permit.
t" APPL CAM UNDERSTAND ND WILL COMPLY WITH ALL NON-POI Issued by: Date
SOU GU TIO _7z"V
Re-roofs
nalu pplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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)?❑Ycs �o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contami7N.
cfincd by the Bay Area Air Quality Management all new mat-,rials for inspection.
District?
C3 Yes
I have read the hazardous materials requirements cr Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 34.1 understand that if the huilding
docs of acurrently �atcnant,that it is my res nsihility to notify the occupant of theW.
reyu met to iss mra c«tirreate Of Signature of Applicant Date
Owner o thorized agent Date
All roof coverings to be Class"B"or better
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