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CITY OF CUPERTINO --
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BUILDING DIVISION PERNUT
BUILDING ADDRESS:
PERMIT NO.
1
OWNER'S NAME
PBRMrr ISSUB DATE
PHO
CONTROL NO.
650)701-1500
ARCHrIEcrfENGINEER:
BUILDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (wmmencing
with Section 7000) of Division 3 of the Business and Professions Code. and my license is
in fun force sole eft
DEMO OF EXTNG OFC S PC ; NO STRUCTURAL -1,2 0 O O SQ
License a Lie. i 1Z� (OZZ
, ,
Date thContractor
AIZCHiI&CiS DECLARATION
1 understand my plus shall be used as pubt1c necat�
Lxmwd Professional
OWNER -BUILDER DECLARATION
1 bereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Bud— and Professions Code: Any city or county
which nequirrs a permit to construct, ilea. improve. demolish, or repair any anstbum
prior to its issuance, also «suites the applicant far such permit to file a signed staumrau
that he is licensed porauant to lbe provisions of the Contractors L imme Law (CMpta 9
Sq. Ft. Floor Area '
Valuation
(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
000
Section 7031.5 by arty applicam for a permit subjects the appileant La a civil penalty, of
500)
APN Number
Occupancy T Yl�
p y
not more than five hundred dollars (5
31602106 . B 5
❑ L as owner of the property, or my employees with wages at their sale compensation,
Required Inspections
win do the work and the structure is not Intended or offered for sale (Sec. 70K Business
and Profeasioro Code The Contractor's L.imme Law does not apply to an owner of
property who builds or Improves thmeon. and who does such wort himself or through his
awn eoployem provided thou such Improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner-
bunder win have the bu dett of proving that be did not band or improve for purpose of
sale.).
❑ L as owner of rho property, am exclusively conu acting with licensed contractors to
construct the pmjea (Sec. 7044. B-mess and Professions Coda) The Coouactoes U
cane Law does not apply to an owner of property who builds or improves thereon, and.
.
who contracts for such projects with a contractor(s) fitrrued pursuant to the Convactoei
Lkeam Law.
❑ I am exempt under See B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the foBawing declarations
❑ 1 haw and will maintain a Certificate of Cmtsernt to self -imam for Worker's Compen-
cation, as provided for by Section 3700 of rho Labor Code, for the performance of the
work for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Insurance, a required by Section
3700 of the labor Code, for the performance of the wort for which this permit is issued
My Workeeei Compensation Lwwce carrier andPolky number am:
" " E" No.: 1 S 204A—O
CFRTWICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section reed not be completed If the permit is foram hundred dams (S 100)
or lest)
I certify that In the performance of the work for which this permit is issued, I stun not
employ any person In any manner so as to becoute subject to the Wortcrd Compe ss"on
Laws of California. Data
AppBgm
NOTICE To APPLICANT: If, alter making this Certificate of Exemption, you should
become subject to the Watces Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revalued.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performnoce of
the work for which this permit is issued (Sec. 3097, Col. C)
Landis Nun
Lenders Address
I certify that I have read this application and sure that the above information is
correct. I agree to comply with all city and cowry ordinances and state Iowa relating to
bunding conoA)ction• cod hereby authorise repremuLives of [his dry to cum upon the
above -mentioned property for Inspection purposes
agree La"ve, indemnify and keep harmless the City of Cupertino agsimx
laabli, tt casts and expenses whkh may in awry way accrue sgalosa said sty
In o granting of Ihl 1
A IC U STANDS AND COMPLY WITH AI1. N N-POINT
Issued by: Date
SO ENS. I �/
Re -roofs
Type of Roof
V o
Si ofApoph tractor HAZARDOU DISCLOSURE Date
the applicant orfatwe buildin occupant store or handle baardouu material
as della� by the CuperUm Mundd Code. Chapter 9.12. and tine Health and Safety
Code, section 25532(a)7
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
cam the applicant or future building occupant use egaipmrcot or devices which
emit hznrdom air conuminants is by Uoe Boy Area Air Quality Management
all new materials for inspection.
District?
❑ Yea No
I mad the hazardous materials requirements under ❑ apter 6.95 of [be Califor-
Hoal & et Code. Sadao 25505.25533 and 25534. I understand than if the builcRog
does no d have a tenor, thatit is my resp9psibility to notify tine of the
requ) bmuw met af2cenircataofa
Signature of Applicant Date
1p ?r9
All roof coverings to be Class " " or better
g
Date
or auth agent