07060033 CITx OF CUPERTINO
BUILDING DIVISION PERMIT ` i GT '1
PERMIT NO.
BUILDIf 9ftES%ORTHGLEN SQ BARBARA M F I SCHER 07060033
G U PERMIT ISSUE DATE
OWNER'S NAME: 06/05/2007
BARBARA M FISCHER
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
p Zo LICENSED CONTRACTOR'S DECLARATION Job Description
V P I hereby affirm that I am licensed under provisions of Chapter 9(commencing MOVE KITCHEN LIGHTS,MODIFY GUEST/MASTER
Z with Section 70(l())of Division 3 of Ute Business and Professions Code,and my license is
!may in full force and effect. BATH,MASTER/GUEST CLOSERTS,NEW SUBPANEL, GARAGE
t vn Z License Class Lic.A
o Dam contractor LIGHTING, NON STRUCTURAL.
F w ARCHITECTS DECLARATION
i a,a
a I understand my plans shall be used as public records
>yU
LL h Licensed Professional
.0w OWNER-BUILDER DECLARATION
3 e i hereby affirm that 1 am exempt from the Contractor's License Law for the
.p o 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
a" prior to its issuance,also requires the applicant for such permit to rile a signed statementFt.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q $23000
e.t= (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 ppb Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3164106 1:'l9 b Number P Y YP
not more than five hundred dollars($500).
❑I,as owner of the property,or my employees with wages az 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 Contractor's 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.).
I,as owner of the property,am exclusively contracii�g with licensed contractors to
truct the project(Sec.7044.Business and,Profesons Code:)The Contractor's li-
cense Law does not apply to an owner ofprojkny who builds or improves thereon,and.
who contracts for such projects with a cone s]thce
LAutsuant to the Contractor's
License Law.
❑lam tie under i B&P C f�thi
n
Owner Date
WORKER'S CO P SATiON DECRATION
I hereby affirm under penalty of perjury Otte of the following declarations:
�]I have and will maintain a Certificate of Consent toself-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.
❑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 Worker's 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 fpr one hundred dollars($100)
or less.)
i certify that in the performance f the work for which th" permit is" d,I shall not
employ any person in any m so az become subje�the Wo Compe li
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making is Ccrd cate or Exemption,you shou d
become subject to the Worker's Compensation p " ns of Ute Labor Code,you must
,z forthwith comply with such provisions or this permit shall be deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
(.-�t•r I hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(See.3097,Civ.C.)
W A Lender's Name
z Lender's Address
U 0 I certify that i have read this application and state that.thc above information is
correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction.and hereby aulhorire rcpresentati4es of this city to enter upon the
W above-mentioned property for inspection purposes. /
a (We)agree to save,indemnify and keep harmless tho City of Cupertino against
liabilities,judgments,costs and expenses which Riiy in an way accrue against said City
U z in consequence of granting of this permit. Date r —c�
APPLICANT ERST DS AND WIL PLY ALL NON- Issued by:
SOUR E O
Re-roofs �--
Signatu of ApplicanUConttactor Dare 'I Of F.00f
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
fi
❑Yes ONO If a roof:s 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 Arca Air Quality Management all new n iaterials for inspection.
District?
❑Yes ❑Nu
I have read the hazardous materials requiremempimderchapter 6.95 of the Califor-
nia Health&Safety Codc,Sections 25505,25533 and55 :1 understand that if the building
docs not c ntly have a tenant,that it is my res tbility to Ty the occup of Date
re uirc which st be met prior l i a Ccruf a of Occupan Signature of Applicant
All roof coverings to be Class"B"or better
caner or authorized agent Dam/