07020163CY OF CUPERTI]
BUILDING DIVISION
BUILDING ADDRESS:
7
ARCHITECT/ENGINEER:
PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed 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.
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional --- --- — -
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit t h construct, alter, improve, demolish, or repair any structure
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
(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
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (3500).
❑ 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
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.).
4 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Bu ' and Professions Code:) The Contractor's Li-
cense Law does not pply to an ow r of roperty who builds or improves thereon, and
who contracts fors h projects wi a co actor(s) lic nsed pursuant to the Contractor's
License Law.
❑ lam exempt er Seo. B & P C o is re n
Owner Date
JIL RKER'S COOEITSA11ON DECLARATION
I 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-
non, 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is f one hundred dollars ($100)
or less.)
I certify that in the perf ante of the rk or whit is permit is issued, I shall not
employ any perso as ome su ect to the Workers' Compensation
Laws of California.
Applicant
NOTICE 7`0 AP : If, a is Certificate of Exemption, you should
become subject Workcr's C rosalloin 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 (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
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
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, and �ify and keep harmless the City of Cupertino against
liabilities, j gmenls, costs a ex nscs which may in any way accrue against said City
in conseq ce of the gra ng of his permit.
APPLIC UNDER AND AND L COMPLY WITH ALL ON -PO T
SOURC Ti
?.� a
Si r 7 ican ontractiaDa
HAZARD009 MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
[3 Yes � No
Will the applicant or future building occupant use equipment or devices which
I hazardous air contaminants as defind by the Bay Area Air Quality Management
nsrict? 0
❑ Yes o
I hav ad the&Icnaml,
als requirements undcrChapter 6.95 of the Califor-
nia Health afetyCo5.25533 and 25534.1 understand that if the building
docs not c my hais mY responsibility to notify the eupant mf the
rcuui o issuance of a Certificate of Oc�ancy.
MAIN LOBBY Job Description
1;q. Ft. Floor Area
Issued by:
Re -roofs
Type of Roof
APN Number
Required Inspections
Valuation
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature AApplicant
All roof coverings to be Class "B" or better
Date