08100129c o LICENSED
� z �d with Section 7000) of Division 3 of the Business and Profusions Code. and my license is
"'4 y in full force and eff f. Lk. x
1 z-33
Dec. Class — 6
qqq Dale r . Contractor
eAZT^ __> ARCHITECTS D ON
rt I understand my plans shall be used as public mcm
Lit L)
CIn Licensed Professional
0 OWNER -BUILDER DECLARAnON
' 1 hereby of inu that 1 am exempt from the Contractors License Law for the
o OO following reason (Section 7031.5, Business and Professions Code: Any city or county
m Pei which requires a permit to construct, eller, improve, demolish, or repair any structure
n Z prior to its issuance, also requires the applicant for such permit to rile a signed statement
Y< that he is licensed pursuant to time previsions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions. Code) or
y .. that he is exernpt thcmfrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the appliant to a Civil penalty of
not more than five hundred dollars ($500).
❑ Las owner of the property, or my employers with wages as their sok compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code. The Contractors Uccmc Law dors ort 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 ate not Intended or offered for sale. If,
however. the building or improvement is sold within one year of completion, me owner -
builder will have the burden of proving that he dad not build or improve for purpose of
Towne of the property, am exclusively contracting with licensed contactors to
construct the project (Sec 7044. Business and Professions Code:) The Contractors U.
cense Law does not apply to an owner of property who builds or improves theean. and
who contras for such projects with a contractor(s) licensed pursuant to the Contactors
l cense Law.
I am exempt under Sea . B & P C for thin mason
OwneDue
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
Plflh.ve and will maintain a Cersiliate of Consent to self -insure for Wonkefs COmpen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is Lasum d
❑ 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 Workees Compensation lnmwcc carrier std Policy number ate:
Carrie; Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cfhs rection need not be completed If tie permit as for one hundred dollars (SI00)
or less)
1 certify that in the performance of the work for which this permit is issued, 1 shall nes
employ any person in any matup so as to become subject to the Worked Compensation
Laws of CaI
Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
j~i rte-+ 1 hereby affirm that there is 4 consutcdon lending agency for the performance of
CY the work for which this permit is Luted (Sec. 3097, Civ. C.)
aA Undoes Name
= Z Lenders Address
U C 1 certify that I have read this application and state that the above information is
LL cormcL I agree to comply with all city and county on0tuntes and a= laws relating to
Q Vbuilding 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 of Cupertino against
En liabilities. judgments, costs and expenses which may in any way accrue against said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
4-31-006
Signature of Applitam/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hranious material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
[3 Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air eUntaminanta as med by the Bay Area Air Quality Management
District?
Yes o
ADD 2 CAR GARAGE &
427SO
Ft. Floor Area
APN Number
Issued by:
Re -roofs
Type of Roof
Required Inspections
an
Valuation
Uccupancy Type
Date—? (!JS
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.
I have mad the hazsndous materials requirements under Chapter 6.95 of the Califor-
nia Heal uh & Safcly Code. Sections 25505.25533 and 25534.1 understand that if tie building
docs not currently have a tenant. that It is my responsibility to notify the occupant of the
requI� arcmens which must be met prior to s„M,- of Certificate of Occupancy. signature of Applicant
a t a
Date
owner or uthorved agent Dae . All roof coverings to be Class 'A”' or better