07030122BUILDING DIVISION PERMIT
IDGE LN
OWNER'S NAME:
PHONE:
ARCHITECTIENGINEER:
c a LICENSED CONTRACTOR'S DECLARATION
ul P: 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z vOt with Secdon 7000) of Division 3 of the Business and Professions Code, and my license is
y in full force and effect.
? License Class Lic.ii
❑ Date Contractor
ARCHITECTS DECLARATION
a I understand my plans shall be used as public records
av
in Licensed Professional
j OWNER -BUILDER DECLARATION
a i 1 hereby affirm that 1 am exempt from the Contractors License Law for the
20 following reason. (Section 7031.5, Business and Professions Code: Any city or county
9 which requires a permit to construct, alter, improve, demolish, or repair any structure
z y prior to its issuance, also requires the applicant for such permit to rile a signed statement
x that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
t, (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
Vthat he is exempt therefrom and the basis for the alleged exemption. Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars (5500).
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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
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 employers, 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
sib:.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors 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 Contractor's
License Law.
I am exempt under Sec. . B & P C for this reason
Owner '/=----�.'-` Date
Rd COMPENSATION DECLARATION
I hereby affirm under penalty 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.
❑ 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 Workers Compensation Insurance carrier and Policy number are:
Carrier: 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 cenify that in the performance of the work for which this permit is issued, I shall not
employ any person in an manner�so to b �r(t5subject to the Workers' Compcnsadon
Laws of California, ate LL
Applicant �'+ �"—
NOTICE TO APPLICANT: If, atter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith Comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that 1 have read this application and state that the above information is
correct. 1 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
ahove-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 permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS_--__
61,21 7
Signature of Applied tt/Contracfd'r �"'_ Daic.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
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
District?
❑Yes EJ No
I have read the hazardous materials requirements underChapter6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534. I understand thatif the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which rr st.be_ afrior to issuance of a Certificate of Occupancy.
TBD — TO BE DETERMINED
PERMIT NO.
07030122
PERMIT ISSUE DATE
06/12/2007 _
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
ADD 708 SF TO EXISTING HOME, ADD MASTERBEDRM,
LAUNDRY FAMILY, PORCH
REMODEL KITCHEN, NEW ROOF
Sq. Ft. Floor Area
35906025 ,Vp Number
Issued by:
Re -roofs
Type of Roof
$225090
Required Inspections
Valuation.
Occupancy Type
Date b—
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.
Signature of Applicant
Date