07080240 77-77-7777
CITY OF CUPERTINO
BUILDIN�DIVISION PERMIT +carr .�T+aR IIEM�TI(Il�
BUILDING ADDRESS: PERMIT NO.
20304 PINNTAGE PY TBD - TO BE DETERMINED 07080240
PERMIT ISSUE DATE
OWNER'S NAME:
08/28/2007
SANITARY NO. CONTROL NO.
JE:
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
Z LICENSED CONTRACTOR'S DECLARATION
a Job Description
m C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
i m with Section 7000)a(DivLGon 3 of the Business and Professions Code,and my liccrtsc is SKYLIGHT WINDOW REPLACEMENT
a c. in fuliMCEC7SDECLARATiON
; Z LicenALic.B CONTRAC'POR: M.L. NIELSON CONSTRUCTION
LO
E o pare COntr
i a a I understand my plans shall be used as public records
�aV
U.l- Licensed Professional
t a OWNER-BUILDER DECLARATION
aI hereby ai-rrrm that 1 am exempt from the Contractors License Law for the
:in o following reason-(Section 7031.5,Business and Professions Code:Any city or county
:I V which requires a permit to construct,alter,improve,demolish,or repair any structure
t"N prior u)its issuance,also requires the applicant far such permit to file a signed statement Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
is (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $5100
that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 36947015 Number
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 Required Inspections
and Professions Code:The Contractors 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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The ConW=Oes li-
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
n I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I 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 Work s Compensation insurance carrier and Policy numb:
Cartier. � _Policy No.1�Lv(. •� b
CE[t I TE OF EXEMPTION FROM WORKERS'
le G COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify 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
,J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
Fr ems. I hereby affirm that there is a construction lending agency for the performance of
Cl. the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
jz Lcndees Address
U 0 1 certify that 1 have read this application and state that the above information is
lL ► correct.1 agree to comply with all city and county ordinances and state laws relating to
OU building construction,and hereby authorize representatives of this city to enter upon the
i]•i above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City _ 7
U Z in consequence of the ranting of it. Date
►- APPLICANT U STAND AND ILL OMPLY WITH ALL NON-POINT Issued b}
SO
? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new r laterials for inspection.
District?
❑Yes °
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25 533 an534.t understand that if the building
does not currently have a tenant, at it is y res ibility to notify the occupant of the
req' menu hi stbemet -or ssuanc fa Certificate of () Signature.of Applicant Date
All roof coverings to be Class"B"or better
mer or authorized agent Date