07080081 CITE'OF CUPERTINO ♦� -p- '
BUILDING DIVISION PERMIT VIJR 9Q `I) +1?RATIfJ�i'
BUIL IN9 DRESS: PERMIT NO.
1HYANNISPORT DR TBD TO BE DETERMINED 07080081
'ER'S NAME: PERMIT ISSUE DATE
SUMEI LEE 09/21/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB 1vfECH
L O O D
o
p LICENSED CONTRACTOR'S DECLARATION
U`F I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
:z with Section 7400)of Division 3 of the Business and Professions Code,and my liccrhsc is ADD FAMILY ROOM, MASTER BEDROOM & BATH EXPANSION
' y in full fora and effect
: z License Class Lic.# —
F Date Contractor
ARCHnECCSDECLA } REMODEL KITCHEN, BATH#2 LIGHTING @ DR. , REMODEL
i a 1 understand ml plans shall be used as public records (�Jt�tireC t
;ate INCLUDES RE-ROOF & STRUCTURAL
a y Licensed Professional
H OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Cale:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
2 that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 Sq.Ft.Floor Area Valuation
e.H (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $114172
°$ 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 Number Occupancy Type
not more than five hundred dollars(5500). 35611022
❑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
and Professions Code:The Contractor's License Law does not apply to an owner of Required inspections
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 projects with a contractor(s)licensed pursuant to the contractor's
License Law.
❑I am exempt under Sec B&P C for this reason
ter 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-insurc for WorkcesCompen-
sanon,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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundrW 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 m rtncr so bcggmp s�bje�tie�he Workers'Compensation
�� Laws of Califomi;i,2 !/
Applicant llI C4/=,
NOTICE TO APPLICANT:If,after Mking 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
(e r,-. I hereby affirm that there is a construction lending agency for the performance of
N> the work for which this permit is issued(Sec.3097,Civ.C.)
Wes,A (enders Name
2 z (enders Address
U 0 I certify that I have read this application and state that the above information is
Lt. ►c correct-I agree to comply with all city and county ordinances and state laws relating to
building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
rte+rA liabilities,judgments,costs and expenses which may in any way accrue against said City
(�'Z in consequence of the granting of this permit.
►-+ APPLICANT UNDERSTANDS(\ND WILL COMPLY WITH ALL NON-POINT Issued by Date
SOURCE REGULATIONS.
> �(� Re-roofs /
Signature of Applican ntranrtor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
s defined by the Cupertino Municipal Cale:,Chapter 9.12,and the Health and Safety
de,Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed.
El Yes ONO
Will the applicant or future building occupant use equipment or devices which If a roof i;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 materials for inspection.
District?
❑Yes ❑No
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
docs not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
Owner or authorizcd agent Dare- _ All roof coverings to be Class"B"or better