07050120 771.
CITY OF CUPERTINO
BUILDING DIVISION PERMIT �� TRt � � Q �
PERMIT NO.
BU11nfffEstUPERTINO RD TBD — TO E E• DETERMINED 07050120
LGL l PERMIT ISSUE DATE
OWNER'S NAME:
HA, JOHN 05/15/2007
SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: INSTALL NEW WOOD FENCE BLDG ELECT PLUMB MECH
p p LICENSED CONTRACTOR'S DECLARATION (2GNTRAGTG.F PA±B FOR Bt
Job Description
UF- I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z, with Section 7000)of Division 3 of the Business and Professions Code,and my license is
t y in full force and effect.
j ? License Class Lic.#
Date Contractor
ARCHITECTS DECLARATION
7 a< I understand my plans shall be used as public records
)qV
'a y Licensed Professional
a OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License law for the
poa 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
prior to its issuance.also requires the applicant for such permit to file a signed statement Valuation
-?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
rF (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i 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 AP14 Number Occupancy Type
not more than five hundred dollars(3500).
❑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 Required Inspections
and Professions Code:The Conuactoes 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.).
1,as owner of the property,am exclusively contracting with licsnse tractors to
co truct the project(Sec.7044,Business and Professi 6�o Contractors Li-
cause Law does not apply to an owner of p -,Mfb bu'wTfr improves thereon,and
who contracts for such projects with a r lieefi'd pursuant to the contractor's
License Law.
❑1 am exempt undScSeC �_,B&P C fa
Dale
Owns WORKEt COMPENS ON DECLARATION
I hereby affirm under penalty of perjury one of the following Iarad
❑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 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 for one hundred dollars($100)
or less.)
I certify that in the performance of the w9rk-forwhich,lhis*rtnit is issued,t shall not
employ any person in any man to bee eat to the Workers'Compensation
Laws of California.
Applicant
NOT1C6 A :lf,a to making thisc t tt a of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall be deemed revoked.
7_ 2 CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction pending agency for the performance of
(Y > the work for which this permit is issued(Sec.3097,Civ.C.)
W A
Lender's Name
Z
Lender's Address
U 0 I certify that 1 have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state paws relating to
Ubuilding construction,and hereby authorise representatives of this city to enter upon the �\
(.0 above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmicss the City of Cupertino against
Hr/1 liabilities,judgments,costs and expenses which may in,pny�ey'ac'e iia said City
U Z in consequence of the granting of this perroit:— / r
�. APPLICANT UNDERSTANDS*196 WILL CQjdF�Y'�TH ALL ON- INT Issued by: x Date
SOURCE REGU N$.
�S n Re-roofs
tgnaturc o t/C nDO Type of Roof
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant or future building occupant store or handle It ous material
as defined by the Cupertino Mi'pal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall )e inspected prior to any roofing material being installed.
E3 Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove -
emit hazardous air conLaminal as defined by the Bay Area Air Quality Management all new materif 1S for inspection.
District?
❑Yes No
I have read the hazardous materials requirements uttderCha 5 of the Califor-
nia Health&Safety Code,Sections 25505,25533arid755 crstandthatifdtcbuilding
does not currently have a tenant,that it 3 m o stbility to notify the Occup t of
requirements which m -t aon=of a Certificate of Occupan . Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner or authorized agent Da