07010184 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS: `_ _ <�1,� ,, �h0��1/'� PERMIT O. u
O '�V1j`J�'/ RYJA` {{{✓✓✓VVV��+ ` , PERMIT LSSU DATE
OWNER'S NAME:. �� 1�/ c Or' �V 1 1 V
t)NE:
r i�•/YV/ SANITARY O. CONTROL NO.
' BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p a LICENSED CONTRACTOR'S DECLARATION Job Description
4 V 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing J /
L Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is O�fi/1r C`yj�
v=y in full force and cffecL l/ r✓,v11Y/�/ ��rwncl (� IJ�V
�2? License Class Lic.#
E-
in Date Contractor
UJ ARCHITECTSallbeused
DECLARATIONpublic
�fi rear r
t understand my plans shall the used as public records
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Wy Licensed Pnhfcssional
< OWNER-BUILDER DECLARATION
AH.]
1 hereby affirm that 1 am exempt from the Contractors License Law fort the
00 following reason.(Section 7031.5,Business and Professions Cale:Any city or county
K which requires a permit to construct.alter,improve,demolish,or repair any atrocture
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft. Floor Area Valuation
G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q O
x t $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of UN Number
not more than five hundred dollars(5500).
i
❑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 Contractors License Law does 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
sate.).
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 Contractor's
License Law.
❑1 am exempt under_ ,Sec B&P C for this reason
,,.vner (y/lJr� Date 11//13 13
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 Compcn-
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 Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for anc hundred dollars($100)
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 Tjs to become subject to the Workers'Compensation
Laws of California.Date
Applicant ■
NOTICE TO APPLICANT:If,after making this Ccrtiricatc of Exemption,you should
become subject to the Workers Compensation provisions of the tabor Code,you must
�Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 2 CONSTRUCTION LENDING AGENCY
HC/) I hereby affirm that there is a construction lending agency for the performance of
tx > the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
I certify that I have read this application and state that the above information is
LUL O correct.I agree to comply with all city and county ordinances and state laws relating to
C> building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned properly for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
,may liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. Date —
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCEREG!M
��3r�b7 Re-roofs
Signature of of Applicant/Comractor Date Type of I:oof
HAZARDOUS MATERIALS DISCLOSURE yP
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
-ole,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
[3 Yes qNo
Will the applicant or future building occupant use equipment or devices which
If a roof .s installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new r iaterials for inspection.
District?
C]Yes NNo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requircmcnts whi h must be met prior w issuance of a Certificate occupancy. Si Applicant Date
1�3� I° gnaturt:oAll roof coverings to be Class"B"or better
Owner or authorized agent Date