07090076 CITY OF CUPERTINO e� �, TORIE}RMATION'
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
n o?-� r- TIF' A ZA. 131 11 MC!T_GTj PE r A
'4'S NAME:
B - S CONTROL NO.
PHON
i ? — BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION Job Description
0
p 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
u with Section 7000)of Division 3 of the Business and Professions Code,and my license is
in full fWZ��
"�� INSTALL=.NG CANOPY, MONUMNT & STORE FRONT SIGNS.
i LicenseLic.A P� �__..
G Dare Con traMor
ARCHIT ECI S DECLARA ON
I undersand my plans shall he used as public records
a
V
H Licensed Professional
? OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
j Op� following reason.(Section 703 1.5,Business and Professions Code:Any city or county
ti which requires a permit to concoct,alter,improve,demolish,or repair any structure
> prior to its issuance,also requires the applicant for such permit to file a signed statementE3590801) . 00
q Ft. Floor Area Valuation
C G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or2_n rN
that he is exempt therefrom and the basis for the alleged exemption.Any violation ofAPN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500).
❑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 docs 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.).
0 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
Date
WORKER'S COMPENSATION DECLARATION
I hereby affum under penalty of perjury one of the following declarations:
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.
Q 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.
M Worker's CoMpentation Insurance carrier and Policy number are: ?d3
.LLy>ttL71FICA E ls+r-I P77 NO..
CERTIFICATE OF EX ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certifv 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
i 0 forthwith comply with such provisions or this permit shall be deemed revoked.
i
�+ CONSTRUCTION LENDING AGENCY
— I hereby affirm that there is a concoction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
z Lender's Address
0 1 certify that I have read this application and state that the above information is
rr cortc.L I agree to comply with all city and county ordinances and state laws relating to
Ubuilding concoction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes. .y
' (We)agree to save.indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit. Date /Z �
►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by.
SOURCE REGULATIONS.
Re-roofs
Signature of Appli ontractor MATERIAL °'e T of Roof
RDOUS S Type DISCLOSURE
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 OK
If a roof i 3 installed without first obtaining an inspection,I agree to remove
Will the applicant o future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new rr aterials for inspection.
District?
O 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 ft building
docs not currently have a tenant,that it is my responsibility to notify the occupant of the Date
requirements which must be met prior to issuance of a Certificate f cupancy. Signature of Applicant
`�—^ All roof coverings to be Class"B"or better
Owner or authorized nt Date