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CITY OF CUPERTINO
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BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
19030 STEVENSTBD
— TO BE DFTERMINED
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OWNER'S NAME:
PERMIT 15RM DATE
A CONTROL NO.
ARCHITECT/ENGINEER
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
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Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
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INSTALL VA [ PR RECPVERU SUSTE, FPR EXON/ROTTEN
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Date
ROBBIE SERVICE STATION. TECHNLGY&IN—STATN DIGNSTC
RCHrt'ECTS DECLARA710N
I understand my plans shall be used as public records
EQUPMNT@ EXTNG ROTTEN ROBBI E FUEL CTR
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reason- (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit to consuuci, alter, improve, demolish• or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
titan he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
6 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit subjects tine applicant to a Civil penally of
not more than five hundred dollars (S300).
37511072.00
❑ L asowner of the property. ors my employewith wags astheir sole compensation,
Required Inspections
will do the work and the structure Is not Intended or offered for sale (Sec.70". 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
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, un exclusively contracting with licensed contractors to
construct the project (See. 7044. Business and Professions code:) The Contractors Li-
cense Law dos not apply to an owner of property who builds or Improves thereon, and ,
who contracts for such projects with a contraaar(s) licensed pursuant a the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 ha+ 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
of the Labor Code, for the performance of the work for which this permit is issued-
'
My Workers Cglmpens1atlon Insurance carrier and Policy number are: C�
Carrier. TG1 t� r�t/I /I l Policy No.: � %� a+M
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CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
C11is section need not be completed if the permit is for one hundred dollars ($100)
.
or Iasi.)
1 certify that in the performance of the work for which this permit is issued, 1 stall not
employ any person in my manner so as to become subject to the Workers' Compensadon
Isws of California- Date
Applicant
NOTICE TO APPLICANT: If, alter 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 of this permit shall be deemed revoked.
CONSTRUCTIONLENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
'
the work for which this permit is issued (Sec 3097, Civ. C)
Lendees Name
,
Lender's Address
1 certify that I have read this application and state that the shove information is
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cortCeL I agree to comply with alI 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, cops and expenses which may in any way ac'cme against said City
in consequence of the granting of this permit
9
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SOURCE REGULATIONS.
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Re -roofs
Type of Roof
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Signature f I pnU on trot Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building o cupamt pore or handle hanrdous material
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u de0ned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safely
Code, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Ya No
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 haisrdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes No
1 lulw read the by oats materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currcntiy haw a tenant. that it is my responsibility to notify the occupant of the
requirement hp m t b ? t ee ra c«tir to aer.
Signature of Applicant Date
All roof coverings to be Class '%" or better
care
Owner audarvcdagcnt