08120034 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ��� � "' 0 '
PERMIT NO.
BUILDING ADDRESS:
TBD - TO BE DETERMINED
1699 S DE
PERMIT ISSUE DATE
OWNER'S NAME:
SArh
A 9 CONTROL NO.
eHo
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
u ad C LICENSED CONTRACTOR'S DECLARATION Job DCSCnptlOn
u I hereby affirm that I am licensed under provisions of Chapter 9(commencing
with Section 70(X))of Division 3 of the Business and Professions Code,and my license is UPGRD TO MOTOR FUEL DISPENSORS
H in full force and effect
Z License Class p Date Contractor
F,
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
DC6
4 C In Licensed Professional
arA 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
Z p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K V6 which requires a permit to construct alter,improve,demolish,or repair any structure
w prior to its issuance,also requires the applicant for such permit to rile a signed statement Ft.Floor Area Valuation
G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
9=$ (commencing with Section 7000)of Division 3 or the Business and Professions Code)or $60000
y 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
nut more than fire hundred dollars(M). 36610120 . 01
0 I,u owner of the property,or my employees with wages as their sole compenudon,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs 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.).
,t,A I,as owner of the property.am exclusively contracting with licensed contractors to
tohstmet the project(Sec.7044,Business and Professions Code:)The Contractors 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 Contractors
License Law.
O I am exempt underlSs B&P C FOE this mason
0,n Date
COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Consent to self-insure 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.
0 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 Compensation insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Icss)
I certify that in the performance of the wo for which this permit is issued,I shall not
employ any person in any manngr14AS to onto subject to the Workers'Compensation
Laws of Califomia.Date
Applicant
NOTICE TO APPLICA :!f, r irsking this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z� CONSTRUCTION LENDING AGENCY
(~.t.�• 1 hereby affirm that there is a construction lending agency for the performance of
Q!h7 the work for which this permit is issued(Sec.3097,Civ.C.)
W QLenders Name
] Lenders Address
1 certify that I have ad this application and state that the above information is
LUL" corremad
I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon Ute
U shove-mentioned property for inspection purposes.
CL (We)agree to save.indemnify and keep harmless the City of Cupertino against
rte- to liabilities,judgments,costs and expenses which may in any way accrue against said City ll
V Z in consequence of the granting of this permit. Date
1-+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
tSOURCEREGU N
Re-roofs —
Signat of 1 tort Da T of Roof
HAZARDOUS MATERIALS DISCLOSURE
Type
of
to applicant or future building occupant store or handle hrrardous 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.
0Yes NNo
Will
a roof is installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
emit ha-rardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes FN.
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the building
doe�Iulhod�.gc.l��'
that it is my responsibility to notify the occupant of the
reqrior to issuance of a Ccrurrate of occupancy. Signature of Applicant Date
L IAAll roof coverings to be Class'. or better
coDa