06100052CITY OF CUFEKI1i
BUILDING DIVISION
BUILDING ADDRESS:
OWNER'S NAME:
LEE KENNE
INE:
ARCHITECT/ENGINEER:
PERMIT
g p LICENSED CONTRACTOR'S UFLLAKAt LUN
U
I- I hcrcby affirm that I am licensed under provisions of Chapter 9 (commencing
z'.. with Section 7000) of Divi ,on
3 of the Business and Professions Code, and my license is
u = H in full force and effec Y
License Class Lic• N
p Date Contractor
t 'u RCHIT•ECI'S DEC RA O
i a < 1 understand my plans shall be used as public records
tyU
'
U. H Licensed Professional
y OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
3
00 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
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
t=- (commencing with Section 7000) of Division 3 of the Busine s 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 mom than rive hundred dollars ($500).
❑ 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 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.).
0 1, 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
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 Compcn-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
vork for which this permit is issued.
] 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.
vty Worker's Compensation Insurance carrier and Policy number arc:
:arrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foranc hundred dollars ($100)
mr 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 t b U c ubject to the Workers' Compcnsation
Laws of CalifomMatc
Applicant �L
NOTICE TO APLICANT: 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 construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namc
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 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.
APPLIC NT UNDERSTANDS AND, COMPLY WITH ALL NON -POINT
SOU EGULATI N ;��
Signature of Applicant/Corkractor Date
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 erf4
Will the applicant or future building occupant use equipment or devices which
tit hazardaus air contaminants as defined by the Bay Area Air Quality Managemeni
District?
❑ Yes C,Cr+u
1 have read the hazardous materials requirements under Chapter 6.95 of the Califar
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not rrcnlly have a tcnanl that it my responsibility to notify the occupant of tht
rcyui nus which m 't t pn iss cc of a Ccr ificate of Oc pansy
Owner or authorized agent
—T Date
PERMIT NO.
NU DESIGN MANUFACTURE 1 06100052
00V
PERMIT ISSUE DATE
SANITARY NO. ' I CONTROL NO,
Job Description
BUILDING PERMIT INFO
ELECT PLUMB
NEW SUNROOM 8X12 (96') WITH ELECTRICAL & NEW SL
6FT FRENCH DOORS
Floor Area
umber
Issued by:
Re -roofs
Type of Roof
Required Inspections
on
15000
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