08120130CITY OF CUPER1 LNU r
BUILDING DIVISION PERMIT��� r
UILDING ADDRESS:
OWNER'S NAME:
ARCHITECTIENGINEER:
a
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
PERMIT NO.
PERMIT ISSUE DATE
Job Description
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
with Section 7000) of Division 3ofthe Businccsand Professions Code, and mylicense is ENHANCES VAPOR RECOVERY PHASE 11 INSTALL
in full force and effect
License Class
Contractor C LEANER / S E PERATOR
Date
Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's 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 statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) ur
that 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 (SSW). 3693941
❑ I, as owner o[ the properly, or my employees with wages as their sole compensation,
will do the work andthe structure is not intended or offered 44, d for sale (Sec. 70Business
and Professions Code: The Conuactoes 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.).
as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
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 Contractor's
Licenset'p,
❑ lamunder Se B & PC for this reason
Owner'� �' �� Dam ✓' I o
_ . WQgKERS-COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hsve and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, u 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 Workefs 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 OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars ($100)
or Icss)
I certify that in the performancepf the work for which this permit is issued. I shall not
employ any pc�s�y�''r any manna"as m become subject m the Workcrs' Compensation
Laws of Californ ,O4411f
Applicant t Uv�L G
NOTICE TO APPL7rrATTI: IT. ificr making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shalt be deemed revoked.
Z t—+ CONSTRUCTION LENDING AGENCY
H
rA I hereby affirm that there is a construction lending agency for the performance of
a > the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lender's Name
■0 z Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LL H cornea I agree m comply with all city and county ordinances and state laws relating m
O U building construction, and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (We) agree to save, indemnify and keep harmless the City of Cupertino against
►F -t t) liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in onsequence of the granting of this permit.
► 1CANT UNeeERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Sb C_LE REG L
JINJ
MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes '0 No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as deftncd by the Bay Area Air Quality Management
District?
❑Yes Nu
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that if the building
d �:mcnts
ntly have a tenant, that it is my responsibility m notify the occupant of the
rcwhi must be mel prior m issuance of a Ccnifj* Oct�p�cyt
OwnervrauWorir&.d agent Dale
Issued b:
Re -roofs
Type of iKoof
Sq. Ft. Floor Area
APN
00
Required Inspections
on
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 lnaterials for inspection.
Signature of Applicant
All roof coverings to be Class ";AF' or better
Date