08110035/ IH
CITY OF CUPERTINO "
BUILDING DIVISION PERMIT ri) ACTC?'RX�Q�
� r
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
PHO S CONTROL NO.
ARCHfI fENCINEER: BUILDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
License Class Lle. If
Date Contractor
ARCHITECTS DECLARATION
1 undcrmod my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
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 sighted statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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
and Professions Code The Contractors 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 employes, provided that such improvements are not intended or offered for sale, lf.
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
scale".)..
Ly-t;' u owner of the property, am exclusively contacting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractors LI-
cc= Law does not apply to sin owner of property who builds or Improves thereat, and
who contracts for such projects with a conuactnr(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under See.
� //- , B & P C for this reason
Owner =. % a
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 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.
❑ 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 Laurance carrier and Policy number are:
Carrier,
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(his section need not be completed if the permit Is for tree hundred dollars ($10lh
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 u to br c subject tgthe Workers• Ctmrpensation
Laws-of Califomi�,.�y- e /
cal >
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such previsions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
i hereby affirm that there is a construction lending agency forthe performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
1 certify that I have read this application and state that the above information is
correct 1 a&= to comply with all city and county ordinances and state laws rclating to
building construction, and hereby suthcrim representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of thts permit.
APPLICANT UNDERSIAN ND WILL COMPLY WITH ALL NON -POINT
SOURCE
Signatrict of Applicant/Contractor , /
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal c. Chapter 9.1 Z and the Health and Safety
Code, Section 25532(a)7
❑ Yes o
Will the applicant or future building occupant use equipment or devices which
emir hazardous air contaminants as def/ned by the Bay Area Air Quality Management
Dtstrict7
❑t-�U'�
Yes
1 have hazardousread the hazardous requirements under Chapter 6.95 of the Califor-
nia Health & Safely Cedc, Sections 25505. 25533 and 25534.1 undersmd tar if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occv
Owner or authorfrtd agent
ADD 364SQ FAM RM, RMDL=NEW I O
CA$EWK@NOOK& DINERM, Job Description
Sq. Ft. Floor Area
APN Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy
Date — 2 g D'
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