07060048 CITI'OF CUPERTINO40
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BUILDING DIVISION PERMIT7.7
PERMIT NO.
BUILII�G�1�DjtESHAZELBROOK DR JUDITH K BOISSICAT 07060048
l �j L� PERMIT ISSUE DATE
OWNER'S NAME:
JUDITH K BOISSICAT 21164 HMELBROOK DR 06/06/2007
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
10 p LICENSED CONTRACTOR'S DECLARATION Job Description
up I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z U with Section 7000)of Division 3 of the Business and Professions Codc,and my license is ADD 2 VE AUX SKYLIGHTS W/NO RAFTERS CUT
y in full force and effect.
n? License Class Lic.#
t—ODare Contractor
u ARCHITECTS DECLARATION
7 d a 1 understand my plans shall be used as public records
)yV
a ti Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
<0.9 which requires a permit to construct,alter,improve,demolish,or repair any structure
u—y prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
_Z} t .Ft.Floor Area
< that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9 `S 1 $22600
2 F Q (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
Ll 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 32655026q.
64 Number Occupancy Type
not more than five hundred dollars($500).
❑L 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 does 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.).
2/1.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-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑1 aPhemb,
Sec B&P C for this reason
OwneDate '61,61,07
RKER'S COMPENSATION DECLARATION
under pertalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Worker'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 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.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
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
0 forthwith comply with such provisions or this permit shall be deemed revoked.
z "" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a convection lending agency for the performance of
(Y. the work for which this permit is issued(See.3097,Civ.C.)
W Q Lender's Name
aLender's Address
U 0 I certify that 1 have read this application and state that the above information is
[1. correct.l agree to comply with all city and county ordinances and state laws relating to
0 U building 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
V z liabilities,judgments,costs and expenses which may in any way accrue against said City
in conece of the granting of this permit. Date
►� APPLI A E STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOUR G ONS. / O
G Re-roofs
Sign/at of App t/ on[ractor are Type Of Rcof
HAZARDOUS MATERIALS DISCLOSURE yp
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)? y All roofs shall be inspected prior to any roofing material being installed.
❑Yes YI No
/////����� If a roof is installed without first obtaining an inspection,I agree to remove
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 all new materials for inspection.
District?
❑Yes kNu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
Urequitly ha tenant,that itis my rcsponibility to notify the occupant of the
m be met prior to issuance of a Certificate�' Signature(f ApplicantDate
7 7 7All roof coverings to be Class"B"or better
r.cd agent Date