06090151CY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
LIE:
)NE:
ARCHITECT/ENGINEER:
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 Lc• R
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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
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).
❑ 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
Z
ownerof the property, am exclusively contracting with licensed contractors to
t 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. B & P C for this reason
❑ I am exemp under Sad%
�/ Date 1
Owner ARK S COM ENSATION DECLARATION
L'
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, 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 arc:
:artier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Faced not be completed if the permit is for one hundred dollars ($100)
n less.)
i certify that in the performance of the work for which this emit is issued, I shall not
:mploy any person in any manner mFsubject t Wortcrs' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: 1f, after making this &rti tiiption, you should
become subject to the Workces Compensation provisions of the bor 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 state laws relating to
building construction, and hereby authorise 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 a granting of this permit.
APP CANT U ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SO RE CATIONS.
Sfgmature of p i t/Con(ractor Date
V,AZARDOUS 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)? ft
�
❑ Yes Ly.rvo
Will the applicant or future building occupant use equipment or devices which
.tit hazardous air contaminants as defined by the Bay Area Air Quality Managcmcni
District?
[3 Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor
nia Health & Safcty Code, Sections 25505, 25533 and 25534.1 understand that if the building
doen
ot c ntly have a tenant, that it is my responsibility to notify the occupant of tht
reyu menr must be met prior to issuance of a Certificate oflOcc�upancz.
Owner or
PERMIT NO. 06090151
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
REMODEL- STRUCTURAL_ ONLY- LIVING ROOM, DINING,
KITCHEN AND ADD LIGHTING. NO PLUMBING/MECHANICA
Sq. Ft. Floor Area
APN Number
37511005.00
Required Inspections
Issued by: .101
Re -roofs
Type of Roof
X11
Occupancy Type
Date a)
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