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CITE' OF CUPERTINO
BUILDING DIVISION PERMIT
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PERMIT NO.
07040087
OWNER'S NAME:
PERMIT ISSUE DATE
THE FORUM
06/21/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
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Job Description
p.
1 hereby affirm that I am licensed under provisions of (commencing
with Section 7000) of Division_ 3 of the Business and Professions Codc, and my license is
REMODEL 496 S F OF THE EXISTING LIBRARY ON THE
in full force and effect Q _1CA \ f, 2'1
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License Class F� Lie.p V`�
SECOND FLOOR -
Date Contractor 'Z,'JL Cty�%5-VLA(i,
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ARCHITECTS DECLA ATION
NO ELECTRICAL, MECHANICAL OR PLUMBING
I understand my plans shall be used as public records•
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Licensed Professional
OWNER -BUILDER DECLARATION
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1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (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.(Chaptcr 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$180000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
�,p�j Number
3 42 54 9 9 9
Occupancy Type
Section 7031.5 by any applicant for a permit sobjects the applicant to a civil penalty of
not more than five hundred dollars ($500). ..
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I, 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.).
❑ 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 Li-
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cense Law does not apply to an owner of property who builds or improve thereon, and.
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
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C]1 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:
❑ 1 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
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My Workers Compensation Insurances carrier ar� Policy number are:
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Carrier.Rt?1?ubt L nuQ� Policy o.: 15oa0AC\_ OU2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he 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, 1 shall not
employ any person in any manner so as to become subject to the Workcrs' Compensation
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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 Lahor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked. '
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
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the work for which this permit is issued (Sec. 3097, Civ. C.)
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Lender's Name
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Lender's Address
I certify that 1 have read this application and state that the above information is
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corecL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
ahovc-mentioned property 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 of this permiL
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Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof G�
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)?
❑ Yrs '�Na
All roofs shall be inspected prior to any roofing material being installed. '
Will future
If a roof is installed without first obtaining an inspection, I agree to remove
the applicant or building occupant use equipment or device which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes )gNu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Heal th&Safety Code, Sections 25505,25533 and 25534.1 understand that ifthe building
docs not currently have a tenant that it is my responsibility to notify the occupant of the
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Date