08120009 CITY OF CUPERTINO ATT
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
6362 BLACKWOOD DR ALLEN HA SMAN
PERMIT ISSUE DATE
OWNER'S NAME:
A CONTROL NO.
,HONE:
BUILDING PERMIT INFO
ARCHITEC(ENGINEER: BLDG ELECT PLUMB MECH
0
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
v 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 ADD NEW REAR PATIO C OVER(181 S Q) I NC LD RE—RF
o,a in full force and effect
-z License class Co tractor 191 .75SQ AND NO STRUCTURL
y Gi Dale ARCHITECTS DECLARATION
19-, 1 understand my plans shall be used as public records
�yU
O H Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
i
no 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 Sq,Ft.Floor Area Valuation
_^< that he is licensed also
to the provisions of the Contracwr's License Law(Chapter 9
Y F$ (commencing with Section 7000)of Division 3 of the Business and Professions Codc)or $15000
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500)• 36917051 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is notintended or offered for sale(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.).
❑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. B&P C for this reason
❑lam:exempt d Se
�
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 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 Compensation insurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(E 100)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person
of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
,Zi P� CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(Y, the work for which this permit is issued(Sec.3097,Civ.C.)
LLl Q Lender's Name
�z Lender's Address
U 0 1 certify that I have read this application and stale that the above information is
V.E'" correct I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
f3. (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit D to ✓
r-- APPLICANT E T DS AND WILL-CO1t4PLY WITH ALL NON-POINT Issued by:
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t'
Dare Type of Roof \ /
HAZARDOUS MATERIALS DISCLOSURE YP
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
Cole,Section 25532(a)? All roofs shall be inspected prior to any roofing material bei4,*talled.
❑Yes 5tNo
If a roof is installed without first obtaining an inspection,I agree remove
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 all new materials for inspection.
District?
❑Yes 'ONO
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currend have ant,that it is my responsibility to notify the occupant of the Date
mquiremcn etprior.to,issuarim ae irteateofoeenPanry. Signature of Applicant
All roof covering
s to be Class W'or better
42
Owner or authorized agent Datc