06100107 CITY OF CUPERTINO �^r �T�x
BUILDING DIVISION V� �R Zfl!' MT�� :
PERMIT
BUILDING ADDRESS: CRAFTSMENS GUILD INC PERMIT No. 0 610 010 7
1723 DOROTHY ANNE WY
PERMTT ISSUE DATE
PER'S NAME:
MR. & MRS . CHEN 1
SANITARY NO. CON'T'ROL NO.
PHONE:
(408) 366-1000
ARCHI I ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o a a 0
o c LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z5 with Section MIX))of Division 3 of dme Business and Professions Code,and my license is
;=y in full force and eftec Sep*? f S 9 3 BATHROOMS, LAUNDRY - NON-STRUCTURAL
t vn Z License Class L1c•#
;t—p Date Contractor
ARCHITECTS DECLARATION
a—,Cl 1 understand my plans shall be used as public records
:a.
U.to Licensed Professional
y OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractors License Law for the
:p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to constructalter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
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 II �t: 0 0 Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sale compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044,Business Required Inspections
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 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 dt P C for this reason
wrier 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 Workees 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 Com ensa'on Insurance carrier and Policy number amn:
Carrier. Policy No.: 000"`�' `7 1 O vA
CERTIFICATE OF EXEMVnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certif-v that in the performance of the work for which this permit is issued,l 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,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F~.t►�. I hereby afrrrm that there is a construction lending agency for the performance of
L�+ the work for which this permit is issued(Sec.3097,Civ.C.)
W A L.endces Name
=z L.endees Address
U 0 1 certify that I have read this application and state that the above information is
LL�+ correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way steric against said City �
U Z in consequence of the granting of this permit. Date 167--t / G�
►-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGU N
Re-roofs
Signature of Applicant/Conttactor Dam Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Munici al Code.Chapter 9.12,and the Health and Safety
.ale,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes 0<1
I have aced the hazardous materials requirements under Chapter 6.95the if th e Calling
ria Health&Safety Code,Sections 25505,25533 and 25534.I understand thatiCthc building
docs not currently have a tenant,that is my responsibility to notify the occupant of the
requirements whichm et 'or nuance of a Certificate of Occupancy. Siture Of Applicant Date
G+ (af l gnaAll roof coverings to be Class "B"or better
Owner or authorized agent Detc"