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07080189 7-777777777777777 CITE'OF CUPERTINO I���RMs`�T�()�• BUILDING DIVISION PERMIT C�NTIC"rU7k PERMIT NO. BUILDING ADDRESS: �' 2'S NAME: SWJ(WIV-2 Q Q 7 CONTROL NO. PHON . BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH i LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I am licensed under provisions of Chapter 9(commencing L) with Section 7000)of Division 3 of the Business and Professions Code.and my license is :y in full force and effect. REVISE 11.C. PARKING ACCESSIBILITY z License Class Lia M p Date Contractor w ARCHITECTS DECLARATION :- --� I understand my plans shall be used as public records a -� Licensed Professional OWNER-BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OC following reason.(Section 703 1.5,Business and Professions Code:Any city or county ti which requires a permit to construct,alter,improve,demolish,or repair any structure " prior to its issuance,also requires the applicant for such permit to file a signed statement c',q Ft.Floor Area Valuation < that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 7$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or t 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 APN Number not more than five hundred dollars(5500). El 1,as owner of the property,or my employees with wages as their sole compensation, 357200313 . 0 0 will do the work,and the structure is not intended or offered for We(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 sal&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,u owner of the Property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's rad 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 Liceexempt ❑I am exempt under Sea .B&P C for this reason // Dale 1/S/7 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 Workers Compensation Insurance carrier and Policy number arc: Cartier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hunched dollars(E 100) or Icss.) 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 Workers'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 Z forthwith comply with such provisions or this permit shall be deemed revoked. O CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of > the work for which this permit is issued(Sec.3097,Civ.C.) 1 A Lender's Name 2 Lender's Address 0 I certify that I have read this application and state that the above information is ► correct I agree to comply with all city and county ordinances and state laws relating to j V building construction,and hereby authorize representaticonstruction, ves of this city to enter upon the W above-mentioned property for inspection purposes (We)agree to save,indemnify and keep harmless the City of Cupertino against jj liabilities,judgments.Coss and expenses which may in anyway accrue against said City Z in consequence of the granting of this permit. Date �^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOURCE REGULATIONS. Re-roofs Signature of Applicant/Comractor Dare T of R oof HAZARDOUS MATERIALS DISCLOSURE Type Will the applicant or future building occupant store or handle hazardous material ^ defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Section 25532(a)? All roofs ;hall be inspected prior to any roofing material being installed. ❑Yes ❑No If a roof i.;installed without first obtaining an inspection,I agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? C3 Yes ❑No 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 requirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date All roof coverings to be Class"B"or better Owner or authorized agent Date