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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PEtuar issuE DATE
PHO
AUUJ CONTROL NO.
4 8 399-0555
ARCHr1ECTIENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
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Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DD) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
POOL EQUIPMNT BLDG RMDL-NO M/E/P ASSOC PROJ
License Class Lac. M
,W
Date Contractor
**BUS LIC FOR MCKENZIE CONST GOOD THRU 2010
ARCHrfECTS DECLARATION
1 understand my plans shall be used its public records
.
Licensed Ptofexdonal
OWNER -BUR -DER DECLARATION
I hereby affirm that 1 am exempt from the Contactors License Law for the
following reason. (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 file a signed sulement
that he is licensed pursuant to the provisions of the Contactors License Law (Chapta 9
Sq. Ft. Floor Area
- Valuation
(commenting with Section 70DD) 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 Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
35709040 MDW S
❑ I, as owner of the property. or my employees with wages as their sole compe nsedon,
.
Required Inspections
will do the work and the structure 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 thereon, and who does such work himself or through his
"
awn employees, provided that such improvements are not Intended or offered for axle. If.
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however, the building or Improvement Is sold within one year of completion, the owner-
bullder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owrrer of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractors LJ-
cc= Law does not apply to in owner of property who builds or improves thereon, and.
who contracts for such projects with a eontr2mor(s) licensepursuant to pursuathe Contractors
Lice= Law.
❑ I am exem tun ec. , B & P C for this reason
-Owner " -zL Date
WRK COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I 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 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:
Carrier. Policy No.:
CERTIFICATE OF E7fEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section creed not be completed If the permit is for one hundred dollars (S 100)
or less)
I certifv that in the performance of the work for which this permit Is issued. I shall not
employ any person in any mjifnor s to become subject to the Workers' Com ensation
Laws of California. Date IN
Applicant
NOTICE TO APPLICANT: ff, after ma&A this Certificate of Exemption, you should
become subject to the Workers Compensat on provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shalt be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby air= the there Is a construcdnn lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
'
Lenders Name
,
Lenders Address
I certify that I have read this application and state that the above information is
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corecL I 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. toss and expenses which may in my way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
SOVRQE It - TTONS.
Re -roofs
Type of Roof
�\ J� Z" 13
Signature ol'ApplicarlVColiffactor Date
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.IZ and the Health and Safety
Code. Section 255J2(a)T ❑ Yes 4-
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 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 Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that if the building
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does not currently have a Lenan6 that It is my responsibility to notify die occupant Of die
require rats which must be met prior to issuance oft Certificate of Occupancy.
Signature of Applicant Date
-' 1 —
All roof coverings to be Class'W' or better
ownsmram' zceat Dare
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