09030022 CITY OF CUPERTINO
BUILDING DIVISION PERT [<Liji
Q �� *
BUILDING ADDRESS: PERMIT NO.
22330 HOME LE IS POOLS 09ftID022
OWNER'S NAME: PERMIT ISSUE DATE
A CONTROL NO.
408) :71-6690
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Cof,pttdg license is
'ova, in full force S`(p�11 SPLIT MAIN DRAIN
v�2 License Lic.M
t m
Date
"Cs Contractor t 3
ARCHITECTS DECLARATION
'dA< 1 understand my plans shall be used as public records
D,U
4 WO in Licensed Professional
y 3 OWNER-BUILDER DECLARATION
y I hereby affirm that 1 am exempt from the Contractor's License Law for the
U00 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 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of 56000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation, 32659999
.
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's Litxase Law dors not apply to an owner of 9 P
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.).
❑1,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-
ccnse 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
License Law.
❑I am exempt under See B R P C for this reason
Owner 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 Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workal1.ef_jompensation Insurance carrier and Policy_yn_h 0_7 D 0(Ti I 6
Carrier, li�C�C O��> —Policy No.:(,�G� lC7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
I 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 Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
0 forthwith comply with such provisions or this permit shall be deemed revoked.
Z 1-4 CONSTRUCTION LENDING AGENCY
rte+ 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.)
W Q Lender's Name
Z
Lender's Address
U 0 I certify that I have read this application and state that the above information is
GL►" corcct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W
above-mentioned rty for inspection purposes.
(Wc)a to K,indemnify and keep harmless the City of Cupertino against
►F-i to liabilities,jud cots ostsand expenses h may in anyway accrue against said City
V z in consequen of c granting of this it. '
'i APPLICANT DERSTANDS AN WILL OMPLY WITH ALL NON-POINT Issued by: Date
SOURCEU ATiONS. f— 3—C-
6
Re-roof's _
S' afore of Applicant/Contractor Dare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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)? All roo's shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
1 have re the ardour materials requireEleate
apter 6.95 of the Califor-
nia Health&Sa!ty C ,Sections 25505.25533stand that if the building
docs not torten ve a tenant that it is my tify the occupant of the
requirements w h ust be met priorof Occupancy. Signature of Applicant Date
All roof coverings to be Class''"or better
Ow or authorized agent Date