06090230CITY OF CUFhKJLLIN"
BUILDING D1v1s1oN PERMIT �CO:TNTI
t PERMIT No. 06090230
BUILDING ADDRESS:
( OWNER'S NAME:
PACIFIC GAS AND ELECTRIC C
)NE:
ARCHITECTIENGINEER:
O z LICENSED CONTRACTOR'S DECLARATION
u0 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z with Section 7000) of Division 3 of the and Professions Code, m^cense is
a in full force an 4$ 57 "'�
License Class Le• R
p Date Contractor��
Fra ARCHITECTS DECLARATION
i a Q I understand my plans shall be used as public records
U.)yV
G H Licensed Professional
OWNER -BUILDER DECLARATION
3 2 1 hereby affirm that I am exempt from the Contractor's License Law for the
co following reason. (Section 7031.5, Business and Professions Code: Any city or county
.0 El which requires a permit to construct, alter, improve, dcntolLsh, or repair any structure
H prior to its issuance. also requires the applicant for such permit to rile a signed statement
c that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
a h (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
r that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
0 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 docs 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.).
❑ 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 contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
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1 hereby affirm under penalty of perjury one of the following declarations:
:] I have and will maintain a certificate of Consent to self -insure forworkees 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.
My Worker's Compensatio surance carrierand Policy number
mber am,
Carrier. ��Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor 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, alter 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 (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I 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 stale laws relating to
building construction, and hereby authome 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 consenrr Iquence of the granting of this permit.
Boor tkaWr)F. tS'taaFDS AND WILL COMPLY WITH ALL NON -POINT
Signature of Applicant/Contractor tsars
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes am
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District? t�
Yes
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
niaW4lLh & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building
docs n t urrently have a ant that it is my responsibility to notify the occupant of the
require ts wh' l prio of a Certificate o Occup cy.
ZI v
Owner or authorized agent Date
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
Job Description
REPLACE IN -GROUND CLARIFIER
Ft. Floor
Required Inspections
Issued by:
Re -roofs
Type of Roof
BUILDING PERMIT INFO
Occupancy
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
All roof coverings to be Class "B" or better
Date