07020071 CITX OF CUPERTINO p� y�T�TT «„ C�11'TGT�CJ INJJI�IVAAT ()N'
BUILDING DIVISION i Ei�lvll l
PERMIT NO.
BUILDING ADDRESS:
30224. 1211BB RD -- — U A
OWNER'S NAME:
S T CONTROL NO.
V
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
n o a a
Z LICENSED CONTRACTOR'S DECLARATION Job Description
0
j_ I hereby affirm that I am licenced under provisions of Chapter 9(commencing
with Section 7000 of Division 3 of the Business and Professions Code,and my license is
in full force and effect. 2 STORY SFDWL-1ST: 2 019 ' , 2ND: 15 8 0 ' GARAGE:
7_ License Class Lic.#
Date_ Contractor 7 7 5 ' , PATI 0: 3831
a
ARCHITECTS DECLARATION
•� t understand my plans shall be used as public records
Licensed Professional
< OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
i O following reason.(Section 7031.5,Business and Professions Code:Any city or county
�i 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 S Ft. :%or Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
(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 APN Number ccupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). 36202028 . 00
0 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 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.).
ux�s 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 imanproves thereon,and.
who contracts for such projects with a contractor(s)licensed pursut to the Contractor's
License Lawyer
0 lam extpi under Sec B&P C f this
_ D
WORKER'S COMPENSATION DEC RATION
I hereby affirm under penalty of perjury one o e following declarations:
aaoe and will maintain a Certificate of Cone to self-insure for Worker's Compen-
.....on,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
[:11 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.)
1 certify that in formancc tc ork f whjcL his p is issI s�all not
employ any pe n' any manner o o c p I oil 6m nsation
Laws of a.
Applic
NOTIC APPLICANT:If,after making this Certificate of Exemption,you ould
become ser 'cct to the Worker's Compensation provisions of the Labor Code,y must
Z forthwith c ply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
V) I hereby affirm that there is a construction lending agency for the performance of
.>-t the work for which this permit is issued(Sec.3097,Civ.C.)
Q Lender's Name
z Lender's Address
0 1 certify that I 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
U building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments•costs and expenses which in 'n any way true against said City
z Inconsequer1cc
of the granting of this permit. Date
—' APPL of
. NO W MP TH ALL N-P INT Issued by:
SOU EGULATI
Re-roofs
Si natureofApplicant/Contractor °are Type Of Roof
HAZARDOUS MATERIALS DISC OSURE
Will the applicant or future building occupant st or handle bar ous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? t All roofs shall b-,inspected prior to any roofing material being installed.
p Yes
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, agree to remove
tarardous air contaminants as defined by the Bay Area Air Quality Management all new material;for inspection.
ict? i _i
❑Yes Qii6
1 have read the hazardous material rements un pier 6.95 of the Califor-
niaHealth tyCode,Sections 25 3and 25 rstand that if the buil'ng
docs not y have a tenan my respo to notify the pant the
regia which ust be watt o eo nature of Applicant Date
All roof coverings to be Class"B" or better
w cr or authorized agent atc