09030021CITY OF CUPERTINO
BUILDING PEWYEIT
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DIVISION
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BUILDING ADDRESS:
PERMIT NO.
11
OWNER'S NAME:
PERMIT LSRM DATE
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55 1RI�-TERgifieN Ph
S CONTROL NO.
ARCHrr=/ENGINEER:
BUILDING PERMIT INFO
REMOVE & INSTALL 10 NEW
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LICENSED CONTRACTOR'S DECLARATION
DOUBLE PANE WNDS & 1 Job Description
1 hereby affirm dot 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of DivWon 3 of the Business and Professions Code, and my license is
^- ^ T- -^ ^ ^ ^ ^ -- - ^ ^ - - - ^ ••
in full fora and effect.
License Class Lic. f
.
Dale contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I 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 const ucL alter. Improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rick a signed statement
mat 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
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
APN Number
Occupancy
P CY Type
not more than five hundred dollars (x500)
❑ I, as owner of the property. or my employees with wages as their sok compensation,
will do the wort, and the structure Is not intended or offered forsalo (Sec. 7044. Business
Required Inspections
and Professions Cade: The Conuactor's License Law dos 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
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The Comracwr's U.
cease Law does not apply to an owner or property who builds or improves theran, and.
who contracts for such projects with a con wits) licensed pursuant to the Conwcwr's
L,icenee Law.
❑ 1
WORKERS COMA ATION DECLARATION
I hereby affirm under penalty of perjury one or the following deeluations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sadon, as provided for by Section 3700 of die 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 or the labor Code, for the performance of d¢ work for which this permit is Issued.
My Worker's Compensation Insurance carrier and Policy number ane:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATIONINSURANCE
(This section need rot be completed if the permit 4 for one hundred dollen ($100)
or less)
I certify that in the performance of the work for which this permit is Issued, 1 sW not
employ any person in anyan b me subject to the Workers' Compensation
Laws of California Da
Applicant
NOTICE TO APPLICANT: f• a cr aldng a of emersion, you should
become subject to the Worker's Compensad provisions of the Labor Code, you must
forthwith comply with such provisions or this pesmil shall be deemed m okcd
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
1 certify that I have read this application and sate dirt the above information Is
'
correct 1 agree to comply with all city and county ordinances and state laws muting to
building consinrction, and hereby authorize representatives or this City a enter upon the
above-mcndoned 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 amts against said City
in consequence of the granting or it
APPLI ANT UNDERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by:Date �r �•-(,/
S ONS
_
Re -roofs
SI orAppliciii/CoAZARl DOUS MATERIALS DISCLOSURE m
Type of Roof
Will the applicant orfuture building octvpantstare or handle hazardous material
as dented by the Cupertino Municipal Code. Chapter 9.12• and the Health and Safety
Cede, 0Yes 25532(a)7
❑Yes 'j�l No
All roofs shall be inspected nor to an roofing material beim Installed.
P P• Y g g
If a roof is installed without first obtainingan inspection, I agree to remove
Pe
WIII the applicant or Nwre building oezupanl use equipment or &-d= which
°roll ha7ardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes [XNo
1 have read the haxxtious materials requirements under Chapter 6.95 of the Caliror-
nfaHealth &Safety Code, Sections 25 533 and 25534.gordcrstandthat iflhebuilding
don mol lly Linc a lenanl 'to nodfy the occupant of the
'"�° "� "ciAe1�pno�MyC"° °r'3
Signature of Applicant Date
All roof covering � s to be Class't " or better
Owner Date'
or wthorned agent
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