07050160 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �j ' 'g�AT��;IR1V�. TI�1N:
BUILDJN8 ggp8EsPERMIT NO.
JOHANSEN DR TBD 0 BE DETERMINED 07050160
lI'S NAME: PERMIT ISSUE DATE
JUDY LIN 05/30/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a'Z
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!00 LICENSED CONTRACTOR'S DECLARATION tion
Job Description
i U r— I hereby affirm that I am licensed under provisions of Chapter 9(commencing p
:Z,j with Section 717((1)of Division 3 of the Business and Professions Code,and my license is REVISION-REMOVE S H EARWALL @ DEN. O R I G #06110037-
0- in full force and effecL
r,y,? License Class Lic.# NO
F O Date Contractor
ARCHITECT'S DECLARATION NEW PEF'MIT.
w V I understand my plans shall be used as public records
m
U.y Licensed Professional
OWNER-BUILDER DECLARATION
j a I hereby affirm that 1 am exempt from the Contractor's License Law for the
.Cc 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} prior to its issuance,also requires the applicant for such permit to file a signed statement
FE he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. FJoor Area Valuation
h-$ (commencing with Section 7000)of Division 3 of Lhc Business and Professions Code)or �"0
it
,,R E that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 te airy applicant for a permit subjects the applicant to a civil penalty of 3753 6 013:17 bl Number Occupancy Type
not mothan five
hundred dollars($500).
❑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
and Professions Code:The Contractor's 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 sak.K.
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 contractus to
construct the project(Sec.7044,Business and Professions Code:)The Contractors L.i-
ccnse 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 Contactors
License Law.
[l 1 am exempt under Sec B&P C for,this reason
Date : n 1,0-2
WORT S COMPENSATION DECLARATION-7L� /
pereby affirm u r penalty of pedury one of the following declarations
❑I have and will m Lain a Certificate of Consent to self-insurc fu 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 Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed if the permit is for one hundred dollars(5100)
or less.)
I certify that in the performance of the work for which this permit is issued.L shall eta
employ any person in any manner sou me jest to the Workers'CompersaLion
Laws of Califon Date
Applicant
NOTICE TO CA :I ng this Certificate of Exemption,you should
become sub' to the Work ' Compensation provisions of the Labor Code,you mutt
.J O forthwith c ply with suc revisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
tYi the work for which this permit is issued(Sec.3097,Civ.C.)
WGti.Q Lender's Name
z Lender's Address
U C) I certify that 1 have read this application and sate that the above information is
rJ Ucorrect.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.
E�a (We)agree to save,indemnify and keep harmless the City of Cupertino against
ti In liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER GULATIONS.
v C Re-roofs
Signatu Applicant/C to
H DOUS MATERIALS DISCLOSURE Type of Ro�f
1111he applic tor future building occupant store or handle hazardous material
af/t'ted by the Cu ino Municipal Code,Chapter 9.12,and the Health and Safety
1,Section 25532(a? All roofs shall be inspected prior to an roofing material being El Yes ❑No P p y g g installed.
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 mai erials for inspection.
District?
❑Yes ❑Nu
I 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 the
require" ms;which must be met prior to issuance of a croificate of ancy- Signature o.'Applicant Date
G
CA All roof coverings to be Class "B"or better
Ow a authorized enl g
r