08100159CITY OF CUPERTINO
BUILDING DIVISION PERNUT
BUILDING ADDRESS:
22446 LINDA ANN CT
OWNER'S NAME.
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby afr rm that [ am licensed under provisions of Chapter 9 (commencing
with SxLion 70(10) of Division 3 of the Business and Professions Code, and my Ikensc is
in full force and effect.
License Class Lk. N `— '
Date Contraewr
AltHIECTS DECLARArION
1 understand my plans shall be used as public records
Licensed Profossional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from LM Contractor's License Law for the
following reaLOn. (Section 7031-5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve. demolish- or repair any structure
prior to its issuance, also requires the applicant for such permit to Gk a signed satemem
that be is licensed pursuant to the provisions of the Contractors License Law (Chap(er 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 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
net mote than five hundred dollars (S500).
❑ L 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 (See 7044, Business
and Profession Code The Contractors 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.).
❑ L as owner of the property, am exclusively contracting with licensed co n actom to
comtrucs the project (Sec 7044. Buairxss Lod Profusion Code:) The Contractor's U.
cense Law does not apply to an owner of property who builds or improves thereon, end,
who contracts for such projects with a cantractor(s) licensed pursuant to the Contractors
Lkease Law.
❑ i am exempt under Sat. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dech"dons
❑ I haft and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 37M of the labor Code, for the performance of the
wort for which this permit is issued.
Z 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's Compensation Insurance carrier and Policy number are:
Carri= i
(rhis section reed not be completed if the permit Is for one hundred doom ($100)
Of 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 Worken' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be locoed revoked.
CONSMUCf10N LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
0e work for which this permit is issued (Scc. 3097, Civ, C.)
Lenders Name
Lindens Address
I ct7tify that i have read this application and sum that the above infomWion Is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise represenmhes 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 accrue against said City
in consequence of the granung of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
SOURCE
DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous material
as defined by the Cupertino Municipal Code, Chaplcr 9.12, and the Health and Safety
Code, Section 25532(a)?
[3 Yes ❑No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants is defined by the Bay Area Air Quality Management
District?
❑Yes No
I have read the hazardous materials requhements under Chapter &95 of the Califor-
nia Health & Safety Code. Sc cuons 25505. 25533 and 25534.1 understand this If the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requirements which mty. +orrbTssuw= of a Ccnifkae of Occu wtcy. ,
FEKMII NU.
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
Job Description
RMDL MSTR BTH& CLST ALTRTN; NON—STRUCT,(100SQ)
Ft.
Valuation
APN Number Occupancy Type
32613070.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
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
Owner or
All roof coverings to be Class' W_ or better