08090082BUILDING DIVISION PERNUT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHr[F.CTIENGINEER:
0 p LICENSED CON'TRACTOR'S DECLARATION
i 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Divis on 3 of the Business and Professions code, and my license is
O H in full force and effect. /1 p q_ '7
z License clLie. N (� V
Date Contractor 0 f f
ARCHITECTS DECLARATION
i 1 understand my plans shall be used as public records
�yU
' Licensed Professional
10
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason. (Section 7031.3, Business and Professions Code: Any city or county
$ Pi which requires a permit to construct, alter. Improve, demolish, or repair any structure
z prior to its issuance, also requires the applicant for such permit to file a signed statement
G 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 he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollar ISM
❑ i, 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 Coda 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
axle.).
❑ i, as owner of the property. am exclusively contracting with limned contractors to
construct the project (Sec 7044, Business and Professions Coda) The Contractors LI-
ccase 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.
[3I am exempt under Sec . B & P C for this reason
Owner Due
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally 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 Workers 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 Compensation insurance carrier and Policy number are:
Carrier 2,k&1,'4 2✓l0/ Policy No.: ?i 000 'It 7
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($ 100)
or Icss)
1 certify that in the performance of the work for which this permit is Issued. I shall not
employ any person in any manner so as to become subject to cite Workers Compensation
Laws of C&lifomiL Due
Applicant
NOTICE TO APPUCANT: If, after making this Certificate of Exemption you should
become subject to the Worker's Compensation provisions of the Labor Coda you must
0 d
forthwith comply with such provisions or this permit shall. he deemed revoke
z 0r CONSTRUCTION LENDING AGENCY
[—t I hereby affirm that there is a construction lending agency for the performance of
yi 7 the work for which this permit is Issued (Sec- 3097, Civ. C.)
WCL A Ludes Namo
.0 Z Lenders Address
U 0 1 certify that 1 have read this application and state that the above information is
U, correct. 1 agree to comply with all city and county ordinances and state laws relating to
C) ` building construction. and hereby authorise representatives of this city to enter upon the
W above-mandoned property for inspection purposes.
CLs (Wer) agree to Save, indemnify and keep harmless the City of Cupertino against
y liabilities judgments.coW and expenses which may In any way accrue against Said City
U z In consequence of the granting of this permiL
►-t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RE�ATIO
Signat ofApplianU on or Dat —T
=on
MATERIALS DISCLOSURE
Will the applicant or future building occupant scare or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(&)7
❑ Yes ONO
Will the applicant or future building occupant use equipment or devices which
emit haiardous air contaminants as defined by the Bay Amer Air Quality Management
District?
❑ Yes do
I have read the hazandous materials requirements under Chapter 6,95 of the Califor-
nia Health & Safety code, Sections 25505.25533 and 25534.1 understand thst if cite building
does not currently 1enan4 that' my responsibility to notify cite occupant of the
reauimmentswhi adh be m or toAssuance of a Certificate of Occunancv. _
Owner unauthorized agent / / Date
cell ate.
Job Description
T.I.—HILTON GARDEN INN -1ST FLR REMODEL.JNCLUDES
ELECTRICAL. PLUMBING AND MECHANICAL NOT INCLUDED.
NO STRUCTURAL OR REROOF.
Sq.
Valuation
APN Number Occupancy Type
31645015.FLR1
Required Inspections
Issued by:
/
Date — f
Re -roofs
Type of Roof
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 'A" or better
IN
PERMIT NO.
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PERMITINFO
BLDG ELECT PLUMB
Job Description
T.I.—HILTON GARDEN INN -1ST FLR REMODEL.JNCLUDES
ELECTRICAL. PLUMBING AND MECHANICAL NOT INCLUDED.
NO STRUCTURAL OR REROOF.
Sq.
Valuation
APN Number Occupancy Type
31645015.FLR1
Required Inspections
Issued by:
/
Date — f
Re -roofs
Type of Roof
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 'A" or better