07030251 CITE'OF CUPERTINO
BUILDING DIVISION PERMIT C3i'� 3GT:.:o]�I1F(pMATION' .
BUILDING ADDRESS: PERMIT NO.
OWNER' NAM :
,N R RD S T CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
j 0 LICENSED CONTRACTOR'S DECLARATION Job Description
p I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
UW with Section 7000)of Division 3 of the Business and Professions Code and my license is
in mu force and erf,cep ADD COVERED PATIO IN REAR YARD
z License Clas Lic. -
_,ZDate Conlraetar
a ARCHITECTS DEC ON
1 understand my plans shall he used as public records
U
�- Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
:10 following reason.(Section 7031.5,Business and Professions Code:Any city or county
'o which requires a permit to construct,alter,improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to file a signed statement
_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Eq.Ft. Floor Area Valuation
-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
3.. 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 APN Number Occupancy Type
not more than five hundred dollars(E5W).
❑1,as owner of the property,or my employees with wages as their sole compensation, 34212033 . 00
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 docs not apply to an owner of q p
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.).
❑I,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 conuactor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent 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.
❑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 arc: ON Z
Carrie a�r@OM.�F I)F� Polity No.:6I1DK QM Z�a
E CATS—O EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhis 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,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 Workers Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
C)
CONSTRUCTION LENDING AGENCY
14 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
A Lender's Name
Z Lender's Address
1 certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
CL (We)agree to save,i cmnify d keep harmless the City of Cupertino against
t� liabilities,judgments,cos d expo which may in any way accrue against said City
Z inconsequence of the ng of s permit.
r, APPLICANT UI; PR AND AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE A NS.
y 7 Re-roofs
Sign Ap Contractor to
HAZARDOUS MATERIALS DISCLOSURE Type of Rc of
Willie applicant or future building occupant store or handle hazardous material
as defined Ify the Cupertino Municipa Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs s Tall be inspected prior to any roofing material being installed.
❑Yes 10 o
Will the applicant or future building occupant use equipment or devices which If a roof is installed without fit Obt ng an inspection,I agree t0 remove
hazardous air contaminants as ned by the Bay Area Air Quality Management all new materials for inspe n.
_.strict?
❑Yes No
1 have read the hazardous teria/33.
cmcnts undcrChaptcr 6.95 of the Califor-
nia Health&Safety Code,Sc 25505and 25534.I understand that if the building
docs not currently have�.tc t,that isponsibility to notify the occupant of the
requirements which st met p' to issuance of a Certificate of Occup S ignature c f Appli nt Date
4 All roof coverings to be Class"B"or better
Owner thorizr agent Dat