07050276CITY OF CUPEK'1'1NU
BUILDING DIVISION PERMIT
BUILDICIQi nTS�OLUMBUS AV
OWNER'S NAME:
GAYLORD, JULIE
,NE:
ARCHITECTIENGINEER:
ce p LICENSED CONTRACTOR'S DECLARATION
v f= commencing
I hereby affirm that I am licensed under provisions of Chapter 9 (
Z iv with Section 70(10) of Division 3 of the Business and Professions Code, and my license is
t y in full fore andL� L� ay
License Class
p Date 91 Contractor
ARCHITECTS DECLARATION
i a < I understand my plans shall he used as public records
)yU
U. H Licensed Professional
O a OWNER -BUILDER DECLARATION
ia 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
Z yy prior to its issuance, also requires the applicant rot such permit to rile a signed statement
e s that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F (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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sale compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Contractor's License Law does riot 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-
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 Contwtoes
License Law.
❑ I 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:
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❑ 1 have and will maintain a Certificate of Consent to self -insure for Workces 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 am:
/� 5, 016 4.61 -
Cartier. N � Policy No: ZC_—�
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
forthwith comply with such provision or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency rot the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. 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
above-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. /-/ !D, 744 0�
Signature of icant/Contractor Date
HAZARDOUS MATERIALS DISCL94URE
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)?
❑ Yes P110
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 ❑
1 have read the hazardous materials requirements undcrChapter 6.95 of the Califor-
nia Health & Safety Code, Section 25505.25533 and 25534.1 understand that if the building
does notc qtly have a tenant, that it is my responsibility to notify the occupant of the
rcquircro is tch must,,4e met prior to issuance of a Certificate of Occupancy.
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Owner or authorized
Date
TBD — TO RE DETERMINED
PERMIT NO.
07050276
PERMIT 1SS1JE DATE
05/30/2007
SANITARY NO. CONTROL NO.
Job Description
BATHROOM REMODEL
CONTRACTOR PAID BL W/ PERMIT FEES
Sq
35618056`.'
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BUILDING PERMIT INFO
ELECT PLUMB MECH
Floor Area $46002 Valuation
Number Occupancy Type
Required Inspections
C wit
Issued by: Date (`7
Re -roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being installed.
If a roof is instilled without first obtaining an inspection, I agree to remove
all new materi�Lls for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better