08100162BUILDING DIVISION PERMIT
OWNER'S NAME:
ADD FAMILY:
o a LICENSED CONTRACTOR'S DECLAPM / 77 A
Uz I hereby affirm that I am licensed under provisions d(Ch!(ft2r 9 (� sag
< with Section 7000) of Division 3 of the Business and Professi mSCotlff. and my license is
a, in full force and effect
z License Class LIc_ rf
n F, a Date Contractor
ARCHTTECrS DECLARATION
< 1 understand my plans shall be used aspublic records
5 a O,{', Licensed Professional
y <J OWNER -BUILDER DECL.ARA71ON
i I hereby affirm that I am exempt from the Contractor's License Law for the
1111 following mason. (Section 1031.5, Business and Pmfesmom Code: Any city or county
m which requires a permit to construct. alter, improve, demolish, or repair any Wvetum
u z N prior to its issuance, alw requires the applicant for such permit to file a signed statement
s < that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
F- $ (commencing with Section 7000) of Division 3 of the Business and Professions CoM) or
that he is exempt therefrom and the buts for the alleged exemption. Any violation of
Section 7031-5 by any appUont for a permit subjects the applicant to a Civil penalty of
mot more than five hundred dollars (1500).
- ❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the smart ue Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or Improves t6acon, and who does such wort 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 riot build or improve for purpose of
sale.).
❑ L as owner of the property, am exclusively contracting with licensed contraetocs to
conatruet the project (Sec 7044, Bumness and Professions Code:) The Contncmes Li-
cense Law does not apply to an owner of property who builds or Improves thereon, and
who contracts for such projects with a cortuwtor(s) licensed pursuant to the Contractor's
License Law.
❑ I am
of the following declarations
❑ I have and will maintain a Certificate of Consent to self-iosme for Worlds Compen-
sadon, as provided for by Section 3700 of the Labor Code, far the performance of the
work for which this permit is Issued
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OP IXEMPTION FROM WORKERS
COMPENSATION INSURANCE
CILLs 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 ismed, I shag not
employ anyperson is an manner so to 6ecomc subject to th Worker Compensation
I. of C.I forrda.
Applies
NOTICE TO Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
0 Z forthwith comply with such provisions or this permit shall be deemed revoked
Z " CONSTRUCTION LENDING AGENCY
T hereby affirm that there is a construction lending agency for the performance of
a, the worts for which this permit is issued (Sec. 3097, Chr. C.)
a0 Lender's Name
Z Lenders Address
U 0 1 certify that I have mad this application and stain that the above information is
(1+ ',"". correct I agree to comply with all city and county ordinances and state laws relating to
0 �U^ building construction, and hereby wthwim representatives of this city to enter upon the
a above -mentioned property for inspectim purposes,
(We) agree to save, indemnify and keep harmless the City of Cupertino against
r/y IlablBtics judgmcns, costs and expenses which may in any way accrue against said City
V 4 in consequence of the grnting of i permit.
APPLICANT UNDERSfAN1 AND WILL COMPLY WITH ALL NON -POINT
souR �
occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9AZ and the Health and Safety
Code. Section 25532(a)7
❑Yes 'XNo
Will the applicant or future building occupant rasa equipmem or device which
emit harardous air contaminants as defined by the Bay Area Air Quality Management
District? y�
❑ Yes xNo
I have read the hazardous( materials requimmnents under Chapter 6.93 of the Califor-
nu �ctyCode. Sectionsh
of a Crnifr„t�6
!� t .
Owner or authorized a Date
PERMIT NO.
PERMIT ISSUE DATE
SANrrARY NO.
,KITCHEN NO
Job Description
Issued by:
Re -roofs
Type of Roof
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
Date 2 —
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's" or better