06100086CITY Of CUPERTINO �ITGTC�I�RII�li(J1y''
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: HARRELL REMODELING INC 06100086
,R'S NAME:
PHONE:
ARCHITECT/ENGINEER:
p p LICENSED CONTRACTOR'S DECLARATION
UP I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z U with Section 7000) of Division 3 of the Business and Professions Code, and mylicensc is
CL. in full force and effect. 7GI 5
= F, License 1 Lic. # - hitt re.1 d 1
p Datc Contracor
mARCHITECT'S DECLARATION
I a < 1 understand my plans shall be used as public records
iyU
' W H Licensed Professional
r
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for Imre
. p o following reason. (Section 7031.5, Business and Professions Code: Any city or county
m which requires a permit to construct, alter, improve, demolish, or repair any structure
t ' ran prior to its issuance, also requires the applicant for such permit to rile a signed statement
;Z <11 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
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).
❑ 1, 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 doessuch 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 Contracoes Li-
censc Law does not rty who builds
mon, and
who contracts for such proje
cts cts with a contractan owner of or(s)licensed pursuant nP o the roves Contractor's
License Law. g & P C for this reason
F1 am exempt under Sec
'nee
Date
WORKER'S COMPENSATION DECLARATION
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PERMIT ISSUE DATE
SANITARY NIT _ CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
REVISION: DELETE 1 HOLDDOWN AND ADD A STRAP
90RIGINAL PERMIT# 06070174
I hereby affirm under penalty of perjury one of the following declarations:
] 1 have and will maintain a Certifrcao of Consent to self -insure for Worker's Compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
-1 I have and will maintain Worker's Compensation Insurance, as required by Section
1700 of the Labor Code, for the performance of the work for which this permit is issued.
Ay Worker's C�RFICATE
ta� carrier and Policy number
:artier. Policy No.:
OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This 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 Workcrs' 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 constructinn lending agency for the performance of
the work fur which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namc
Lender's Address
I certify that 1 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
building construction, and hereby authorize 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.
QANT UND TAND A�WILL COMPLY WITH ALL NON -POINT
10 REGUL an„rs .� I 0
11
'1 lot_
39}'MADOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous materia
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safet)
Code, Section 25532(a)?
❑ Yes ANo
Will the applicant or future building occupant use equipment or devices whicl
emit hazardous air contaminants as defined by the Bay Area Air Quality Managemen
District?
❑ Yes XNo
1 have read the hazardous materials
nia Health & Safety Code, Sections 25505.:
docs�p�,,�urrendy have a tenant, that it "I
re irot4Rds which muJIM%et prior to t
-cmcnts under Chapter 6.95 of the Califoi
and 25534.1 understand that if the buildin
gponsihiliiy to notify the occupant of It
of
Floor Area
APN Number
35701094.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
rim
Occupancy Type
Date
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 of Applicant Date
All roof coverings to be Class "B" or better