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07090059 777777777777777 777777�_7 CITY OF CUPERTINO BUILDING DIVISION PERMIT J INE+(?RM�TIO PERMIT NO. BUILDING ADDRESS: R TTrc: 7:.cii P OWNER'S NAME: SA CONTROL NO. BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH RFM0VF EXISTING WOOD SNAKE, p LICENSED CONTRACTOR'S DECLARATION INSTALL COMP. SINGLE Job Description C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing I S ^LL COMP E Jo. UW with Section 7000)of Division 3 of the Business and Professions Code,and my license is H in full Corce and cCfe ? License Class 9 Lic. p Date Contractor ARCHITECTS DECLARATION T— --� I understand my plans shall he used as public records .Q -U t-" Licensed Professional ?a OWNER-BUILDER DECLARATION o 1 hereby affirm that 1 am exempt from the Contractor's License Law for the jO following reason.(Section 7031.5,Business and Professions Code:Any city or county which requires a permit to consuuct,alter,improve,demolish,or repair any structure } prior to its issuance,also requires the applicant for such permit to file a signed statement Sq.Ft. Floor Area Valuation that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 •r (commencing with Section 7000)of Division 3 of the Business and Professions Code)or L 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 APN Number Occupancy Type not more than five hundred dollars(5500). ❑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 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 die Contractor's License Law. 1 am exempt under Sec B&P C for this mason Owner Dale - 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- ,ation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 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 WorkeesyCoomype�nsation Insurance carrier and Policy number am: Cartier rrr��17 Polity No.:��rrlM4 -Zo✓ CERTIFhCATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed if the permit is far one hundred 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 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 I O forthwith comply with such provisions or this permit shall be deemed revoked. i CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of i the work for which this permit is issued(Sec.3097,Civ.C.) ALender's Name Lender's Address Iz 0 I certify that 1 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 jV building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. GL (We)agree to save,indemnify and keep harmless the City of Cupertino against V) liabilities,judgments,costs and expenses which may in any way accrue against said City }Z in consequence of the granting of this permit. Date /y* APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: SOUR REGULATIONS. 09/11 /G,?- Re-roofs Signature of App]4=vcontractor Dare Type Of R Sof HAZARDOUS MATERIALS DISCLOSURE 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)? / All roofs:.hall be inspected prior to any roofing material being installed. ❑Yes 2<0 Will a roof is installed without first obtaining an inspection,I agree to remove ll the applicant or future building occupant use equipment or devices which it hazardous air contamina;N-. as fined by the Bay Area Air Quality Management all new m iterials for inspection. restrict? ❑Yes 1 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 A Applicant Date 661 it I G� All roof coverings to be Class"B"or better Owner or a thorized kcni Date 07 01 .0059 CITY OF CUPERTINO REROOF CUPEkTINO PERMIT APPLICATION FORM APN# 3 6-9 ' 0 ,/ O O f� Date: Building Address: ,7759 Owner's Name: Phone#: G ��i✓ k /' 401 J 2 S"3 0 9 Contractor: License#: Con act: Cupertino Business License #: Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ wilt-Up roof sphalt Shingles p Asphalt Shingles Er Wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other(Specify) Number of existing coverings ❑ Provide I.C.B.O. Report# ❑ To be Removed ❑ Provide Mfgr.Installation Specs. I Have Read,Understand and Will Comply With Cui)ertino's Tear Off Policy: Job Description: �i�1i✓6- ,�3t��-� ��`�'d Sf�iG�=� ,y�vd��- �� o'f�i`i7iz ,S'L Residential Commercial ❑ ,C-s63 z 5- Fire Fire Zone: Yes ❑ No 7" Confirmed with Planning Del)t. if there are any restrictions: Cost of Project: Type of Construction: Occupant group: Qty. if Applicable Fee ID Fee Description Fee Group BPERMFEE Bldg Permit Fees BUILDING BENERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING t6Z . � b