09010056Vali yr VrJi liltixl\V
BUILDING DIVISION PERMIT
OWNER'S NAME:
ARCHITECTIENGINEER:
o p LICENSED CONTRACTOR'S DECLARATION
LU I' I hereby affirm that I are licensed under provisions of Chapter 9 (commencing
w with Section 70M of Division 3 of the Business and Professions Code, and my license is
in full force and affect.
License Class Lic. 0
t Date Contractor
ARCHITECTS DECLARATION
wC I understand my plans shall be used as public records
G Licensed Professional
y a OWNER -BUILDER DECLARATION
K g I hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
0 which requires a permit to construct, alcor improve, demolish, or repair any structure
;w prior to its issuance, also requires the applicant for such permit to rile a signed statement
^y Q that he is licensed pursuant to the previsions or the Contractor's License Law (Chapter 9
F (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
.. that he 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 penally of
not more than five hundred dollars ($500).
C] I, as owner of the property, or my employees with wages as their solo compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
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.).
56. 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 Contractors
License Law.
❑ I am
Date /
WORKER'S COMPENSATION 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 Wmrkeds Compensation Insurance artier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION 114SURANCE
(This section need not be completed if the permit is for one hundred dollars (S 100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any
--
OF
—ta to making this Certificate of Exemption, you should
become subject to the Worker's Compensdtioa provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
r tai I hereby a[firm that there is a concoction lending agency for the performance or
> the work for which this permit is issued (Sec. 3097, Civ. C.)
a A Lender's Name
Lcndees Address
Q I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction, and hereby authorize representatives of this city to enter upon the
above-mendoncd property for inspection purposes
.4 LI t (We) agree to save, indemnify and keep harmless the City of Cupertino against
y V) liabilities, judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
"t APPLICANT UNDE3 TANDS AND WILL COMPLY WITH ALL NON -POINT
SOU�
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hxrardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
Q Yes 24
Will the applicant or future building occupant use equipment or devices which
emit hazard: air contaminants defined by the Bay Area Air Quality Management
District?
Q
YC
Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &SafetyCode, Sections 25505.25533and 25534.1understand thetifthe building
docs
or a Ccniftcate of occupancy.
m
Of c
r aur xcd agent Date "
PERMIT No.
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PEP MITINFO
BLDG ELECT PLUMB
ADD 70SQ FT TO NEW STORAGE D Q Q
LIBRARY, REMODEL (E) Job Description
Sq. Ft.
Number
Issued by:
Re -roofs
Type of Roof
Required Inspections
Date
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
A]1 roof coverings to be Class %" or better