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BUILDING (DIVISION
BUILDING ADDRESS:
7626 HO_
OWNER'S NAME:
ARCHITECTIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Nith Section 7000) of (Division 3 of thc Business and Professions Code, and my license is
n full force and effect.
License Class Lic. #
Date _ Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby ainn that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
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
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) or
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
not more than five hundred dollars (5500).
❑ 1, 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
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 oroffered 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.).
U4, 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.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with tsgctor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec._ , B & P C for this r rcasonI
Owner
Date
WORKER'S q M81$�R
:S'ION DECLARATION _,
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum for Worket'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 Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workces Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not be complelcd if the permit is forone hundred dollars ($100)
or less)
1 cert[ that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manners as m become subject to the Workcrs' Compensation
Laws of California. (Date
Applicant
NOTICE TO APPLICAY a r making this Certificate of Exemption, you should
become subject m the Wohter's mpensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
1 lu.-mby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
L.endces Name —e
Lender's Address _
I certify that 1 have read this application and state that the above information is
corIreel. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
ahave-mentioned properly for inspection purposes
(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
in consequence of the granting ofthis rmit.
APPLICANT UNDERSTAND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS. / . I—.,- 1—o
Signature of Applicant/Contractor ! l Parc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupantstore or handle harardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes &�No
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
District?
❑ Yes j (Nu
1 have mad die ha;rardotis materials requirements under Chapter 6.95 of the Califor-
nia Hcalth& Safety Code, Sections 25505, 25533 and 25534.1 understand that if dtc building
dors not currently have a renan6 aL it is my responsibility to nodry the occupant of the
requirements which mut b¢ff prior to issuance of a Certificate of Ocicuency. / _ C
nam... —
Job Description
ADD LIVING RM,MASTER BEDRM,1/2 BATH&BAR—REMODEL
KITCHEN,BATH,CONVERT BEDRM TO FAMILYRM.REROOF 19
SQUARES.
Sq. Ft. Floor Area
Valuation
APN Number Occupancy Type
36229003.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class 'A" or better
PERMIT NO.
PERMIT ISSUE DATE
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A b.
8 " "
CONTROL NO.
BUILDING PERMITINFO
BLDG
ELECT
PLUMB
0
Job Description
ADD LIVING RM,MASTER BEDRM,1/2 BATH&BAR—REMODEL
KITCHEN,BATH,CONVERT BEDRM TO FAMILYRM.REROOF 19
SQUARES.
Sq. Ft. Floor Area
Valuation
APN Number Occupancy Type
36229003.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class 'A" or better