07060001LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70W) of Division 3 of the Business and Professions Codc,and my license is
in full force and effect -
License ClassLie. p
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
`J hcrcryy affirm that I am exempt from the Contractor's License Law for the
foilowing•rcason: (Seetiun 7031.5, Business and Professions Code: Any city or county
which requires a pci nit -to construct, alter, improve, demolish, or repair any structure
prior to its issuance, a)sd idquires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions.of the Contractor's License Law (Chapter 9
(commencing with Section7000) of Division 3 of the Business and Professions Ccde)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ I, as owner of the pmperiy, or my employees with wages as theirsole 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. It,
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.).
1, 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-
ccnse Law does not apply to an owner of property who builds or improves thereon, and.
who coritr cts roe sti¢h projects with a contraetor(s) licensed pursuant to the Contractor's
Lice w. 4
I
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 =If -insure for WorkcesCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 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's Compensation Insurance carrier and Policy number are:
Carver. Polity No.:
CERTIFICATE OF EXEMP'170N FROM WORKERS'
COMPENSATION INSURANCE
Crhis section need not be completed if the permit is for one hundred dollars (b100)
or less.)
I ecniry
NOTICE T PP A , a n Ccitffcate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which lhis'permit is issued(Sec. 3097. Civ. C.)
Lender's Name — — -
Lender's Address
1 cenify 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
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purpoms.
(We) agree to save, indcmni fy and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in���mmm qucnce the granting of this permit
AfPA U DERSTANDS AND WILL CO PLY WITH L NO -POINT
. o(ApplicanUContrador D
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantor furore 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)?
p Yes T No
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
District?
❑Yes No
have read the hvardous materials rcyuimme s under Chapicr 6.95 of the Califor-
nia cal &Sale c, Scetiotu 25505, 25533 and 25534. I understand thatif the building
d s n Curren ha a tenant that it is my responsibility to notify the oce ant of the
cu
,. � o
rERMIT NO.
07060001
PERMIT ISSUE DATE
>A T R CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
ADDITION 295', BEDROOM 6, BATHROOM.
Sq. Ft. Floor Area Valuation
pN Number $66112
3 5 71614 9Apa Occupancy Type
. Required Inspections
Issued by:
Re -roofs
Type of Roof
Date I; —
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 "B" or better