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CITY OF CUPERTINO:
A f'
BUILDING DIVISION PERNUT
BURRING ADDRESS:
PERMFT NO.
21870 GRANADA AVE
TBD — TO BE
A CONTROL N0.
ARCHTTFI'r/ENGiNEER:
BURRING PERMrr iNm
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
licensed under provisions of Chapter 9 (comencing
I hereby affirm that I am m
with Section 700M of Division 3 of the Business and Professions Code. and my Beene is
in full force and effem
REVISION —ADDING NEW SKYLIGHTS,NEW WINDOW OPENING
License c etracmr
@MSTRBDRM & RMVD MASTR BATHRM—ORIG#08090187 NO
ARCHr1ECrs DECLARATION
I understand my plans shall be used as public records
NEW PERMIT.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following rason. (Section 7031-5, Business and Professions Code. Any city or county
which requires a permit to construct, alter, improve, demolish, or repair soy svucturo
prior to its issuance, also requires the applicant for such permit Lo file a signed statement
Cbniractor's License law (Chapter 9
Sq. Ft. Floor Area
Valuation
that be is licensed pursant ro the provisions of the
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy T
p y Type
Section 7031.5 by any applicant for a permit subjects the appliant to a civil penalty of
not more than five hundred dollars (S500).
35716024.01
❑ L as owner of the or, my employees with ova u their sole compensation,
P
Required Inspections
win do the work and the structure Is not intended or offered for ask (See. 7044. Business
and Professions Cede: The Contractors License Law aces 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 ovwher-
builder will have the burden of proving that he did not build or improve for purpose of
sak.).
�u owror of the propeny. am exclusively contracting with licensed contrsaan to
eo isvoct the project (Sec. 7044. Business and Professions Code:) The Contractors 1.1-
cr ise Law does not apply in an owner of property who builds or improves then=, and
who contracts for such projects with a contractors) licensed pursuant to the Contactors
License Law.
❑ I am exempt and ere B R P C for this rowan
Owner Date 1 D
RKFR'S MPE ON DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -Insure for Workds Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performarree 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 die work for which this pemit is Ls.sued
'
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CEfiTFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($1013)
.
or less.)
I certify that in the performance or the wort for which this permit is issued. I shall not
employ arty person in any manner �yrh u m bbo�oom subject m the Workers' Compensation
Laws of Califo n.0 /d �, 0
Applicant TIT;_ _I
NOTICE �PP .ICANT: If, eking this Certificate of Exemption you should
become subject to the Workers Compensation provisions of the labor Code. you must
fonhwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hereby affirm tharshere is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namc
,
Lenders Address
i certify that I have read this application and state Thal the above information is
'
cornet 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authoria reprrsemativrs of this city to enter upon the
abort: -mentioned property for inspection purposes
(We) agree to save- indemnify and keep harmless the City of Cupertino against
liabilities, judgments. costs and expenses which zany In arty way &cave against said City
in consequence of the granting of this permiL
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RE LATICu1S.
_
Re -roofs /
,/ Lr
Type of Roof
�`'•
Signat ppli Con Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harudous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section
All
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes ONO'
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or device which
emit havardous air conuirrinariLs u dcrined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes EMU-
1 have read the harmdous materials rcquimmtmts under Chapter 6.95 of the Califor-
nia Health R Safety Code. Sccuora 25505, 25533 and 25534.1 undestand this if the building
toes not currently have a truant that it is my responsibility to notify the occupant of the
requirements whic- be met prior to issuance of Certificate of pay.
Signature of Applicant Date
All roof coverings to be Class'JW' or better
Owner or au6j4cdagent atc