07050257BUILDING DIVISION PERMIT
BUiLD22080
N2 0 ADDRESS:
WALLACE DR
US NAME:
COFFER NORMA
PHONE:
ARCHITECTIENGINEER:
p p LICENSED CONTRACTOR'S DECLARATION
hA F.. I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z w with Section 7000) of Division 3 of the Business and Professions Code, and my license is
a w in full force and effect C Lic 8 24 n
: z License C s
• p Dato Contractor -
AIECHrmcTs DECLARATION
i a < t understand my plans shall be used az public records
>yU
o y Licensed Professional
OWNER -BUILDER DECLARATION
j< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
. n 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
s Z r prior to its issuance, also requires the applicant for such permit to Glc a signed statement
= 0 that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
t- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
L .. 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 (5500).
I• as owner of the property. or my employees with wages az 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
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.).
0 I, as owner of the property, am exclusively contracting with licensed conu actors 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.
rl I am exempt under Sec , B & P C for this reason
r 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.
ave and will maintain Worker's Compensation Insurance, az 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. 3 L% �' (Policy No.: 2 M2201
CERTIFICATE OF EXEM ON FROM W RKERS'
COMPENSATION INSURANCE
(Chis 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, 1 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 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
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
cored. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise 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 WILL COMPLY WITH ALL NON -POINT
SOURCfrWULAT 6
`�� 0 JS1LS/O�
Signature of ApplicanUContsactor Me
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
'-fined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Section 25532(a)?
❑ Yes 131,90—
Will
90Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants az defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chaptcr 6.95 of the Califor-
nia Health & Safcty Code, Sections 25505, 25533 and 25534.1 understand that if the, building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements ust t prior to issu of a Certificate of Occupancy.
a,� -� OSIZ49VO .
Owner or authorized accnt Da& '—y
PERMIT NO.
07050257
VERMIT ISSUE DATE
L� G7
,. SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
WINDOW REPLMNT(VINYL),12 RETROFIT WINDOWS, 1 NF
WINDOW W/WALL CUT DOWN 3",2 ENTRY DOORS. WINDOW
BROKER PD FOR BUS LIC.
q. Ft. Floor
32603039
Issued by:
Re -roofs
Type of Roof
vaivatlon
$9309
uccupancy type
Required Inspections
MECH
All roofs ;hall be inspected prior to any roofing material being installed.
If a roof i; installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant . Date
All roof coverings to be Class "B" or better