08090165
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CITY OF CUPERTINO
PERNM
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BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
CONTROL NO.
ARCHnT=/ENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
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with Section 7000) of Dlvislon 3 of the Business and Professions Code, and my license is
mfull force and effeet
DEMO 2—STORY RESIDENCE. (2400SQ)
License Class Lie. tit
Date Contractor
ARCHnECTS DECLARATION
I understand my plans shill be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 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 required a permit to comstnhct. alter, improve, demolish, or repair any structure
'
prior to Is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Lw (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
APN Number
Occupancy
P y T'Pe
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S300�
37534049.00
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec.7044,Business
and Proressiens Code: The Contractors Lice Law dotes Dot apply to an owner of
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property who builds or improves thereon, and who does such wont 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
sal--).
El-L as owner of the property, am exclusively contracting with licensed contractors to
concoct the project (Sec 7044. Business and Professions Code:) The Contractors Lt-
cause 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.
r thi
❑ I am exempt under Sec! ,
i fl-irm 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 haw 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:
Carrier. Policy No_
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(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 person in any manner so as to bee me subject to the Workers' Compensation
'
Laws of Californis. Dater
AppOcarl I
NOTICE TO APPLICANT: If, after making this Cenificitc of Exemption, you should
become subject to the Woderfs Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be darned revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that tore is a concoction lending agency for the performance of
.
the work for which this permit is issued (Sex. 3097, Civ, C.)
Lenders Name
Lender's Address
1 certify that 1 have read this application and state that the above information Is
'
correct. 1 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 purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments costs and expenses which may in any way scenic against said City
APLICANccofthegranting SA permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
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Issued by: Date G
SOURCE REG �ONS. 1 JJ
P`!i�
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Re -roofs
—
Type of Roof
Signa4re of Applicant/Contraetor IDato
HAZARDOUS MATERIALS DISCLOSURE
Will Ibe applicant or future building occuput.store orhandle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.1Z and the Health and Safety
Code, section 25532(a)7 �f
❑Yes ch"v
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as damned by the Bay Area Alr Quality Management
all new materials for inspection.
I0lstrict7
Yes
I ❑
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cal ifor-
rda Health & Safely Code, Sections 25505.25533 and 25534.1 understand that if ttc building
does not currently have a knant that it is my responsibility to notify the occupant of the
requirements ' must met prio,to of a cc,,mcatc of O ry.
Signature of Applicant Date
t
/
roof
All f coverings to be Class"y�a' or better
g �
Cromer d Date
or authorinagent