06030177 CITY OF CUPERTINO
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BUILDING DIVISION PERMIT � R # T�� ,
BUILDING ADDRESS: PERMIT NO. 06030177
OWNER'S NAME:
PERMIT ISSUE DATE
EVE SUN
..JNE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
o p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
U U3 with Section 7000)of Division 3 of the Business and Professions Code,and my license is
!=y in full force Class Lic.M and effect. g ADDITION 740 ' -MASTER SUITES & FAMILY ROOM
��Z Licenense Cl �� V
t,p Date - Contractor
ARCHITECTS DECLARATION
,a
U I understand my plans shall be used as public records
Oin Licensed Professional
< OWNER-BUILDER DECLARATION
i a 1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a pcmtit to construct,alter,improve,demolish,or repair any structure
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priorto 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 Us Law(Chapter 9 Sq.Ft.Floor Area Valuation
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 70315 by any applicant for a permit subjects the applicant to a civil penalty of 3 AWN 1*W&r 0 0 Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages at their sole 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 q P
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.).
❑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 contractors)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 fine of the following declarations:
❑1 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 Workees Compen a.on Insurance ca 'er and Policy number are:
Carrier. 2 .,No.: 0
-CERTIFICAT9 OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued,1 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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z, CONSTRUCTION LENDING AGENCY
[�►�-� I hereby affirm that there is a construction lending agency for the performance of
Q! the work for which this permit is issued(Sec.3097,Civ.C.)
W Q L.endces Name
aL.cndees Address
U C) 1 certify that I have read this application and state that the above information is
tL correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction.and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
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(We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit. 2— -
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE U ONS.
�. Re-roofs
Signature of Applicant/Con or Date
HA2A OUS MA ALS DISCLOSURE Type of Roof
Will the applicant or utum 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)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ?lo
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 "We
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Calc,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
requirements t must be met nor issuance of a Certificate of Occupan Date
4 � Signature of Applicant
..�' 1':.! ZZD,,/Z�� All roof coverings to be Class"B"or better
Owner ofgu rized agent ' Date