09020017°oo
m
UZZ
n=Z
z-
3eCC�a��'
w o s
yam`
C
o
�
_z
YC
0z
z�
F�
Ix >
W�
UC_
Q E
IL
a
H r/
Uz
CITY OF CUPERTINO
nTsTIa ,�g7-
ft
BUILDING DIVISION PFi1PLY111,
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
A CONTROL NO.
408)271-6655
ARCHr1ECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
-tcen ais
with Section 7000) of Division 3 of the Business and Professions Code, and my license's
in full farce and effecL G 2 - e o
ADD APPX 363 LF NEW 8 ' HI CHAINIM FENC& 2 NEW
License Class LJe. '
Date Contractor
3 X 8
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
SQ SECTY GATES
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 Code: Any city or county
Which requires a permit to camtmc. alto. Improve, demolish, or repair any stnrsum
prior to its issuance, size requires the applicant for such permit to file a signed statement
than he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the B tsin ss 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 arty applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars (SS=
31618025 GATES
❑ 1, u owner of the property. or my employees with wages as their sole compensdon,
.
Required Inspections
will do the work. and the schemers Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The contractor: License Law does not apply to an owner of
property who builds or improves thereon. and who does such wort himself or through his
awe anployem provided that such improvements are not inrennded 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 contractors to
construct the project (Sec. 7044. Business Lod Professions Code:) The Contractors Ld-
conse Law does not apply to an owner of Property who builda or improves thereon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury are 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 Libor Code. for the performance of the
wort for which this permit is Issued
❑ 1 have and will maintain Workers Compensation Insurance, at required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
My Worker's Com.� m htsuuance dumber am:
Carrier: 1a=� i�VS�y icy No.: c;1=- L C/ I
/ Y7
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section reed root be completed lithe permit is for one hundred dollars (SIOG)
or less.)
t 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 Worbers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. If, after mating this Certificate of Exemption, you should
become subject to the Wort es Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed rcvoka
CONSTRUCTION LENDING AGENCY
I 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-)
LendeesName
,
Lenders Address
I certify that I have read this application and state that the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise neprcaenstkves of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and kttp harmless the Gty of Cupertino against
liabilities, judgments, costs and expenses which may in any way acme against said City
in consequence of the granting of this permiL
AP (CANT UNDERSTANDS AND WILL. COMPLY WITH ALL OFON-POUfr
n
Issued by: Date — Vy
U REGULATLONs�
Re -roofs
—
Type of Roof
Signatureure ofof Applicant/Contractor
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hulk hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes
All roofs shall be inspected prior to any roofing material being installed,
l `-' -
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 whim
emit hassrdous air contaminans as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes yv^
I have mad the hussr. oats materiaLr requherlelts weer Chapter 6.95 of the Csllfor-
niaHalth&SafetyCode,Sections25505.25533and25534.1urderstandthrtifthe building
does riot currently have a tenant. that It is my responsibility to notify the occupant of the
requirements which must be met prior to ismance of a Cenincatc of qfcupancy.
Signature of Applicant Date
All roof coverings to be Class ' '' or better
Dew
Owner or authorized agent