07050023 CITE'OF CUPERTINO h T T Bhh
BUILDING DIVISION PERMIT
ESS:DD
BUILD J RPERMIT NO.
��3fi5 S DE ANZA BLVD BARRY SWENSON BUILDER 07050023
r 7R'S NAME: PERMIT ISSUE DATE
3UNKER GREGG C 777 N FIRST ST 05/25/2007
PHONE: SANITARY NO. CONTROL NO.
(408) 287-0246
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CON'TRACTOR'S DECLARATION
v— I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
:z with Section 7000)of Division 3 of the Business and Professions Code,and my license is REVISION—FIRE RATING OF MULTI FAMILY DWELLING,
=*4)y in full force and effect. t '
z License Class_ Lk.ft ,�?•,,+�-- 1 HR
F o Dale Contractor
ARCHn EC I'S DECLARATION SHAFT REVISION ORIG #05030230—NO
1 undcrsta m tans shall sed ubli cords
td� tL� NEW PERIIT
y Licensed Profess al
w OWNER-BUILDER DECLARATION
j a 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
<$E,4 which requires a permit to construct,alter,improve,demolish,or repair any structure
z r prior to its issuance,also requires the applicant for such permit to file a signed statement
=e` that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 .>q.Ft. Floor Area Valuation
u F $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $0
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 Number O
riot more than five hundred dollars(s500). 3 6 619 07 1 q64CCu Occupancy Y Type
❑1,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 Required Inspections
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 contractors)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. B tit P C for this reason
x Date
WORKER'S 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 ca cr and Policy number are:
Cartier. 1JX 19 14%9292121
Policy No.:
CER I XEMPTION FRO S
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
E-+ I hereby affirm that there is a construction lending agency for the performance of
CG the work for which this permit is issued(See.3097,Civ.C.)
Wfs.A Lender's Name
Z Lender's Address
U 0 I certify that I have read this application and slate that the above information is
[>n r correct.1 agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes. r
(We)agree to save,indemnify and keep harmless the City of Cupertino against `
L4,) liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: DateL"7
SOURCE REGULATIONS
� S �� Re-roofs
Signature of Applr on tort ate
HAZARDOUS MA ALS DISCLOSURE Type of Ro)f
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
e,Section 25532(a)?
❑Yes All roofs st all be inspected prior to any roofing material being installed.
�No
Will the applicant or future building occupant use equipment or devices which If a roof is nstalled without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of die
rcquircments which must bet rior to issuance of a Cerificate of qccupan Signature o'Applicant Date
Ate, *01 -5 VS 7 �
Owner or authorized agent bateAll roof coverings to be Class "B"or better