08090086 CITY OF CUPERTINO {
BUILDING DIVISION PERAUT ..,
BUILDING ADDRESS: PERMIT NO.
10655 MARY AVE TBD - TO BE DETERMINED ngngnoR6
OWNER'S NAME: PERMIT ISSUE DATE
PHONE:
A CONTROL NO.
ARCHTIECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a p Q LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z uJ with Section 700W)of Division 3 of the Business and Professions Code,and my license is
''ey in full force and err / REMODEL RESID @ COMM STORAGE(LOC-N-STOR) KITCHEN
j M 2 License Class Lie.N—4a s. '
t-� Date Contracto _ 160 ' BATHRM 50 ' ,OTHER 850 'OFFC&WINDOWS-INCLUDES
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A CTS D LARA
s a I understand my plans shall be used as public records REROOF (2 0 SQ S) & STRUCTURAL.
Dyu
k U.H Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
<p FO following reason.(Section 7031.5,Business and Professions Code:Any city or county
K m which requires a permit to cnnsuvct,alter,improve,demolish,or repair any structure
a Z prior to its issuance,also requires the applicant for such permit to file a signer!statement
_C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
Y F (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or 4 O O O O O
y ,.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollar(55130). 3 2 6 0 6 0 5 0 . 00
❑I,as owner of the property,at my employees with wages as thew 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 (l P
property who builds or improves thereon,and who does such work himself or 111rough his
own employees,provided that such improvemens 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.).
❑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 U.
ecru 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
Owner Date
WORKER'S COMPENSATION DECLARATION
1 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
❑1 have and will maintain Workers Compensation lnswmnce,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit's issued
My Worker's Co ensation Insumn camera Policy number are:
Carrier. 7; �yl r '6
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foranc hundred dollars(5100)
or less)
I cenifv 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 became 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.
Z O CONSTRUCTION LENDING AGENCY
F+ 1 hereby affirm that there is a construction lending agency for the performance of
ai> the work for which Nit permit is issued(Sec.3097.Civ.C.)
0 Lender's Name
Lender's Address
U O 1 certify that 1 have read this application and state this the above information is
4."-' correct.I agree to comply with all city and county ordinances and state laws relating to ,
Q V building construction,and hereby authorize representatives of this city to enter upon the
a above-mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City mf Cupertino against
►F-c rn liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granun of thjrs„ emit.
►-' APPLICAN:EGULA
UND AND WIL PLY WITH ALL NON-POINT Issued by: Date
SOURCE R +
�.5 gRe-roofs
Signature of Applicant/Coniractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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 shall be inspected prior to any roofing material being installed.
❑Yes �No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes �No
I have read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not cumcna t it is my ''t to notify the occupant of the
requireme whi r to issuance of a Ccru cato or occupancy. Signature of Applicant Date
Owner or authorized agent Dam All roof coverings to be Class';q`or better