08120101 777 .,777777!
CITY OF CUPERTINO
BUILDING DIVISION PERMIT `IIZTfIlYw
PERMIT NO.
BUILDING ADDRESS:
1 139 DE TBD —
PERMIT ISSUE DATE
OWNER'S NAME:
S A CONTROL NO.
10
T TTTI
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
U C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
_z m with Section 7000)of Division 3 of the Business and Professions Code,and my license is C OMM u L TI OF EXTNG SPC, NON—STRUCTRL INC LD S E/M/P
=y in full force and effect.
v�Z License Class Contractor (4 8 9 S Q)
t Date
ARCHITECTS DECLARATION
g< l understand my plans shall be used as public records
7,6U
4 O 1n Licensed Professional
OWNER-BUILDER DECLARATION
2<2 I hereby affirm that I am exempt from the Contractors License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K to 9 which requires a permit to convect,alter,improve,demolish,or repair any structure
4;1 1 prior m its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
Y F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $30000
y 9 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(s500). 35910015 . SHOE
❑1,as owner of the property.or my employees with wages as their sole compensation,
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 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 Profrssionts 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 tit P C for reason
❑I am//eml and f sec. u
Ownteh._� 3 .>!•—A Date t �"
ORKEMRUS COMPENSAT70N 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.
❑f 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars($100) ,
or less.)
I certify that in the performance of the work r whic is permit is issued.I shall not
employ any person in any man to onto Iect to the Workers'Com ation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,of making th' 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 OCONSTRUCTION LENDING AGENCY
E.r C/)) 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 QLender's Name
az Lender's Address
U C) I certify that 1 have read this application and state that the above information is
LL H correct.I agree to comply with all city and county ordinances and state laws relating to
0 C> building convection.and hereby authorize representatives of this city to enter upon the
Us
above-mentioned property for inspection purpose
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
H liabilities,judgments,toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date y
►+ APPLICANT UNDERSTAN AND 11�iLL COMPLY WITH ALLINO -POINT Issued by:
SOURC RIiGUi NS. /
i Re-roofs
Signature of Applicant/Contractor Data T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
fi
❑Yea Opt. 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 Area Air Quality Management all new materials for inspection.
District?
❑Yeso,
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hfalth&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
ddiis not currenyy ha tenant.th�it is my responsibility to notify the me t of the
reyuiremcns which ust be melon to issuance�Jf a Certificate r oecup Signature of Applicant Date
f All roof coverings to be Class'JW'or better
Owner or a horized agent Datc