061002070 Zo LICENSED CONTRACTOR'S DECLARATION
U P I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z ' with Section 7000) of Division 3 of the Business and Professions Code, and my license is
' a s in full force and effect.
i h ? License Class Lie. tf
i- m Dale Contractor
ARCHITECTS DECLARATION
i a I understand my plans shall be used as public records
1yU
Licensed Professional
QN
OWNER -BUILDER DECLARATION
j a I hereby affirm that 1 am exempt from the Contractor's License Law for the
0 O following reason. (Section 7031.5, Business and Professions Code: Any city or county
e m Ci 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 rile a signed statement
_ < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F o (commencing with Section 7000) of Division 3 of the Business and Professions Code) ur
4 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 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 forsale (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 compledon, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
- ' .'as owner of the property, am exclusively contracting with licensed contractors to
cbnstmct the project (Sec. 7044, Business and Professions Code:) The Convectors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projec with a convactor(s) licensed pursuant to the Contractor's
License Law. '1
C]I am exempt under Sec. , B & P C f this r azon
Owner Date e j tl-L�
Job Description
REVISION: CHANGE FOUNDATION DETAIL & CHANGE
KITCHEN WINDOW TO GARDEN WINDOW
ORIGINAL: 06010014
Sq. Ft. Floor Area Valuation
$210470
umber
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 Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the wo[k for w ich this permit is issued, 1 shall not
employ any person
Exemption, you should
become subject LoNlic Worker's CompensaticK provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z '~ CONSTRUCTION LENDING AGENCY
rn .�
I hereby affirm that there is x construction lending agency I'mr the performance of
{Y. the work for which this permit is issued (Sec. 3097, Civ. C.)
WG1. A Lender's Name
= 2 Lender's Address
U C 1 certify that I have read this application and state that the above information is
Uy " correct. 1 agree to comply with all city and county ordinances and state laws relating to
C U building construction, and hereby authorize representatives of this city to enter upon the
Uabove -mentioned property for inspection purposes.
0.(We) agree to save, indemnify and keep harmless the City of Cupertino against
ti V1 liabilities, judgments, costs and expenses which may in any way accrue against said City
U 2 in consequence of the grand9g of this permit.
APPLICANT U$DERSTNNDS AND WILL COMPLY WITH ALL NON POINT' Issued by:
SOURCEREGUj-ATIONS( / /
Signature dVApplican[/ Date
HAZARDO S 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 ❑ No
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?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &SafcWCodc,Sections 25505.25533 and 25534. 1 understand that ifthc building
does not currently have a tchant, that it is my responsibility to notify the occupant of the
-� requirements of a CertifiicatePf Oc t�iancy./
Re -roofs
Type of Roof
Required Inspections
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