09010044 CITY OF CUPERTINO � � � Z�� �Nw
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
1175 CRE TL TEVE PERMIT LSSUE DATE
OWNER'S NAME:
ti�fAi#8.2CONTROL NO.
.10
(4 0 8) 255-1461 BUILDING PERMIT INFO
ARCHI•IEC(ENGINEER: BLDG ELECT PLUMB MECH
09 p C LICENSED CONTRACTOR'S DECLARATION Job Description
Qv C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z 0 with Section 7000)of Divisi n 3 of the Business and Professions Code,and my license is REMOD E I : 17 6 SQ KITCHEN (M E P)
in full force and effect.
� z LicenscCl Co�xtors MINOR-STRUCTURAL-NO SANITARY CONDITIONS.
E-0 Dale
nk- ARCHITECTS DEC
I understand my plans shall be used as public records
to
�yU
`�y Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
co following reason.(Section 7031.5,Business and Professions Coda Any city or county
�I, which requires a permit to construct alter,improve,demolish,or repair any structure
u"�' prior err its issuance,also requires the applicant for such permit to file a signed statement S Ft.Floor Area Valuation
-z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q 8 O O 0 O
Yts- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
U52— that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars(5500). 3 6 2 2 9 0,12 . 0 0
❑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.Bus9rtess Required Inspections
and Professions Code:The Contracures 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.).
❑1,as owner of the property.am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Cont=uses Li-
cense Law docs 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. B&P C for this reason
C]I am exempt under Sec
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I hsve 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.
❑1 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 Wor Compensajgia insurance carrier and Policy number am:�/'
Ca rsi7 V/I Policy No.: 776
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Ibis section need not be completed if the permit is for one hundred dollars($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 become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject to the worker's Compensation provisions of the Labor Code,you mast
,J Z forthwith comply with such provisions or this permit shall be dcc=d revoked.
Z� CONSTRUCTION LENDING AGENCY
E 4 F.- 1 hereby affirm that there is a construction lending agency for the performance of
Q!> the work for which this permit is issued(Sec.3097,Civ.C.)
W ALender's Name
►P.
7 z Lender's Address
V 1 certify that]have read this application and state that the above information is
LL E* cortect.I agree to comply with all city and county ordinances and stale laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a (We)agree to.sfve,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgme ,costs and expense;,which may in any way accrue against said City y
()Z i
n g oC thi rmit. Date
r y DS NO WIL COMPLY WITH ALL NO -POINT Issued �y:
/
Re-roo'.s
actor We
HAZARDOUS MATERIALS DISCLOSURE Type o'Roof
Will the applicant or future 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)? / All roc fs shall be inspected prior to any roofing material being installed.
❑Yea 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 defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes °
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safety Code,See 1 25505,25533 534.I u9derstand that if the building
docs not currently have a it ism ponsibili to notify Ute oC upant° the Date
requirements which t e to
anccerk GcatenrOcen ry. �41 SignahlreofApplicant
All roof coverings to be Class'A.'or better
to
Owner or authorize agent