08120099BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCIiTTEC "GINEER:
pp 6 LICENSED CONTRACTORS DECLARATION
c00i 1 hereby affirm Wert 1 am licensed under provisions of Chapter 9 (commencing
Z with Section 700M of Division 3 of tho Business and Professions Code. and my license is
n = y in full form and effect.
j Z License Class Lie.1
r-0 Date Contractor
ARCHITECCS DECLARATION
1 understand my plans shall be used as public records
3 Ct
1: ter. Licensed Professional
`J y OWNER -BUILDER DECLARATION
I hereby a(rrm that 1 am exempt from the Contractoes License Law for the
p 0o6 following won. (Section 7031A Business and Professions Code: Any city or county
li which reVi[w a permit to construct, alter, improve, demolish, or repair any structure
_ y prior W its issuance, also requires the applicant for such permit to fde a signed statement
C that he is licensed pursuant to the provision of the Contactors License Law (Chapter 9
t— (commencing with Section 7000) of Division 3 of the Business and Profession Code) or
that be is exempt therefrom and the basis for the sllcged exemption Any violation of
Section 703l.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (sso0).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
win do the wank. and the structure is not iarendrA or offered for sale (Sec.70K Business
and Profession 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.).
❑ L as owner of the property. am exclusively contracting with licensed centncwrs to
construct the project (Sec. 70". Business and Profession Code') The Contractors Li.
cense Law does not apply to an owner of property who builds or improves thereon. and
who contacts for such projects with a contractor(a) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec. B & P C for this won
Owner
DECLARATION
1 hereby affirm under penalty of perjury one of the following declaratiMc
❑ 1 have and will maintain a Certificate of Consent to self -inure for Workers 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 am:
Cartier. Policy No.:
CERTIFICATE FF —EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for one hundred dollars ($100)
or IML)
I certify that in the performance of the wort for which this permit is issued, I shell not
employ any person in any manner so as iovl(cegrpe supjepjto the Worlmrs' Compensation
Laws of
provision of the Labor Code, you must
,J O forthwith comply with such provision or this peanit shall be domed revoked
z '-"' CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a construction lending agency for the performance of
py % the work for which this permit is issued (Sec. 3097, CIv. C.)
W in Landers Name
z Lenders Address
U O 1 certify that I have rod this application and state that the shoo information is
correct. I agree to comply with all city and county ordinanrces and stem laws relating to
SV' building construction. and heeby mthorire representatives of this city m error upon the
a above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
c4 liabilities, judgments, costs and expenses which may in arty way arose against said City
U 7 in consequence of the granting of this permit.
ram- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/ Q n
7 ICJ
Signature of Appl nuacuor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceupaet stare or handle hazardous •• material
as &food by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 23532(a)?
❑ Yes No
Will the applicant or future building occupant use equipment or devices which
emit harirdon air contaminants as del' by the Bay Area Air Quality Management
District?
❑ Yes o
I have: read she harandats marcrials n:ptmm nt- under Chaprrr 6.95 of the Califor-
nia Health & Safety Code, Section 25505.25533 and 25534.1 understand that if the building
does not curtondy have a tenant. that It is my responsibility to notify the poccupant of the
issuance of a Certificate of Occu ! �.
Owner or au a agen Date
PERMrr NO.
ngi ?nn99
PERMIT! ISSUE DATE
CONTROL NO.
BUILDING PERMrr INFO
NEW DECK(182SQ),REPLC 8' 1
WNDW^W/ 6- ^T^ �TT! _ ^ Job Description
Sq. Ft. Floor Area
Number
Issued by:
Re -roofs
Type of Roof
Required Inspections
Date
Valuation
Type
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's' or better