07080122 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT `+�Tk '-
BUIL1 D ESS: PERMIT NO.
T N PORTAL AVE TBD TO BE DETERMINED 07080122
R'S NAME: PERMIT ISSUE DATE
"I, HOWARD O 09/17/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION Job Description
tit1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
2 with Section 7000)of Division 3 of the Business and Professions Code,and my license is DEMO A S:=NG L E FAMILY DWELLING
"e in in full force and effect.
v�Z License Class Lic•#
t
in
Date Contractor
.a ARCHITECTS DECLARATION
i a a I understand my plans shall be used as public records
LU
W HLicensed Professional
y< OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's 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
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pursuant x provisions of the Contractor's License Law(Chap(er
o the S 1.Ft. Floor Area Valuation
eEn
t_ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $11000
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(ESt10). 31629004
UlJ
❑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 Cade:The Contractor's License Law docs not apply to an owner of 9 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.).
a1.as owner of the property,am exclusively contracting with licensed contractors to
coAtruct the project(Sec.7044.Business and Professions Code:)The Contractoes 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 exemp2�_
J B&P C for)his asonson
a Date '
O ER'S COMPENSATION LARATION
1 hereby affirm under penalty of perjury one of the following declarations:
0 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 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 Workees 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 one 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 so as to beComc subject to the Workers'Compcnsauon
Laws of California.Dptq rr !
Applicant jQtfT
NOTICE TO APPL(CAM:If,after making 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
[~i I hereby affirm that there is a construction lending agency for the performance of
fx the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
aLender's Address
U O I certify that I have read this application and state that the above information is
U. r c correct.I agree to comply with all city and county ordinances and state laws relating to
O U building construction.and hereby authorize representatives of this city to enter upon the
Lta above-mentioned property for inspection purposes.
o
f1. (We)agree to save,indemnify and keep harmless the City of Cupertino against
fes+t/j liabilities,judgments,costs and expenses which may in any way accrue against said City �J
U'Z in conseq oC the granting of this permit. Date r 'f
►� APPLIC the
AND WILL COMPLY WITH ALL NON-POINT Issued by: —�
SOUR
Re-roofs
Su nature of Applicant/Contractor Dare T Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupantstorc or handle hazardous material
-defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
e,Section 25532(x)? All roofs s1-all be inspected prior to any roofing material being installed.
❑yes KN.
If a roof is
Will the applicant or future building occupant use equipment or devices which 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?
C]Yes 1.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&SafellQedc,Sections 25505,25533 and 25534.1 understand that if the building
does not curre have a tenant,that it is my responsibility to notify the occupant of the
requiremc w�mtt;t be m t prior to issuartcc of a Certificate of Oc an . Signature o.'Applicant Date
Owner or authari�cAll roof coverings to be Class"B"or better
I agent Dare
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