06100167 CITY OF CUPERTINO :#
BUILDING DIVISION PERMIT �� lT� R IiQIiMT� N'
BUILI G D ESS: PERMIT NO.
V (�
T CALVERT DR TBD TO BE DETERMINED 06100167
'SR'S NAME: PERMIT ISSUE DATE
Gy:B= FERNANDEZ 03/15/2007
SNE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION
Lu F i hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z ru with Section 70(X))of Division 3 of the Business and Professions Code,and my license is DEMO S FDWL
y in full force and effect.
? License Class Lic.ff
F Date Contractor
ARCHITECTS DECLARATION
< I understand my plans shall be used as public records
qU
O y Licensed Professional
rn OWNER-BUILDER DECLARATION
< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
$tc which requires a permit to construct,alter,improve,demolish,or repair any structure
Z prior to its issuance,also requires the applicant for such permit to file a signal statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
I—$ (commencing with Section 70D0)of Division 3 of the Business and Professions Code)or $15000
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 ofNumber Occupancy Type
not more than five hundred dollars(5500). 37519020'O
❑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 We(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License taw docs not apply to an owner of q P
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.).
60 CI 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 Contractor's
License law.
b ❑I am t under Sec. B&P C for 0.re o
$ er Date
7affirm
KER' COMPEN DECLARATION
I herebynderpenalty of perjury one of the following declarations:
❑1 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 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 aced not be completed if the permit is Cor one hundred dollars(S 100)
or less.)
I certify that in forinancc the work for which this permit is issued,1 shall not
employ any pe on• any man r u to become deet to the w Compensation
�7 laws of Calif ' .Date
Applicant
NOTICE A CAM:11f.after making th t icate of Exemption,you should
becomes ject m the Worker's Compensation provisions of the Labor Code,you mast
0 forthwi 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
Yi� the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name
Z Lender's Address
I certify that 1 have read this application and state that the above information is
4► correct.1 agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
" (We)agree to save,indemnify and kee harmless the City of Cupertino against
liabilities,judgme os and expenses w ' ay in any y accrue against said City
'Z in consequent the ting of this pe, it.
APPLICA UN RSTANDS AN CO Y WiTH ALL N N4NT Issued by: DateSOURCE G TIONS.
Re-roofs
Si�dc,.:�Illy
fAp tcant/Contracto re
HAZARDO S MATERI ISCLOsu Type of Roof
the applicant or future building occupant store or handle hazardous materia)
the Cupertino Munici I Code.Chapter 9.12,and the Health and Safety
le,Section 25532(a)?
r-1 Yes o All roofs shall be.inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is instal ed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materi_41sior inspectio
District?
❑Yes Nu
i
I have read ardous materials re cnts u der Chapter 6.95 of the Califor-
nia Health&Safc C ,Sections 25505, 33 d .1 understand thatif the building _ p
does not Curren ve a tenant,that i ' s ibility to notify th Occup of the
requirements must bemet'n rssuao o,4 Certificate of upon S1Qj}a eof Applicant Date
Owner o uthdrircd agent Date
All roof coverings to be Class"B"or better