09030044CITY OF CUPEKITN(J T1L3► C? I� ATI F , I
BUILDING DIVISION PERMIT
BUILDING ADDR
10231
'NER'S NAME:
PHOT
ARCHITECI7ENGINEER:
u p p LICENSED CONTRACTOR'S DECLARATION
m C I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z m with Section 7000) of Division 3 of the Business and Professions Code, and my license is
� in in full force and effect ^ (
Lic. i
n LD to Class _ Contractor A4
A CHI7ECTS DECLARATION
L'i
I understand my plans shall he used as public retards
�yU
O H Licensed Prufcssional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors cense Law for the
00 following reason. (Section 7031.5, Business and ProfessiLions Code: Any city or county
e m � which requires a permit to construct, alter, improve, demolish, or repair any structure
4— rn prior to its issuance. also requires the applicant for such permit to rile a signed statement
G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Y F $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
ythat 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
not more than five hundred dollars (5500).
❑ I. 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 (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
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.).
❑ I, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors u.
cense Law does not apply to an owner of property who builds 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
ier Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
] 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
tation, 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 Workers Compensation Insurance carrier and Policy
l number are: p4,S
Carrier /tZ.9 �P d,J ION �IG fs Polity NYY ��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is Cor one hundred dollars ($100)
or less)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
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 deemed revoked.
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.)
Lender's Name
Lenders Address
I certify that I have read this application and state that the above information is
corcct. I agree to comply with all city and county ordinances and sure 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, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND W L COMPLY WITH ALL NON -POINT
SOURCE
3 i
Si rc o ApplicanVContncror te
HAZARDOU ATERIALS DISCLOSURE
Will the applicant or future ilding occupant store or handle hazardous material
as defined by the Cupertino Municipal odc. Chapter 9.12, and the Health and Safety
ode, Section 25532(a)?
❑ Yes °
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfped by the Bay Arca Air Quality Management
District?
❑Yes °
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califon
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
docs not curcnd have a tenant, that it is my responsibility to notify the occupant of tea
requirements Occupant I
PERMIT NO.
09030044
PERMIT ISSUE DATE
SA CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
DEMO IVTERIOR PARTITIONS, I
CEILIN3, AND FINISHE 3ob Description
Issued b
Re -roof,
Type of Roof
Sq. Ft. Floor
Required Inspections
Valuation
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
All roof coverings to be Class'.. or better
Date