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CITY OF CUPERTINO
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BUILDING DIVISION PEPJvHT
�77: � 0
BUILDING ADDRESS:
PERMIT NO.
3 INFINITE LOOP
TBD T BE DETER
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OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PER MIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with sa� 7oouaecon 3 or da Business ad Professions code, ad my license is
and effect.
C OML T I INT RMDL 8 9 4 S Q EXT SRVR LAB , ADD, DEDCT
LiceDate�° Co �r w. °�a.�eh.n
24 ��
ARCHnECrsDECLARATION
I understand my plans shall be used as public records
COOLNG 4 LAB, INCLD CHI LLR IN BASMNT DIRCTLY
BELOW
Licensed Professional
OWNER -BUILDER DECLARATION
1 hcrehy affirm that 1 am ncmpt from the Contractor's License Law for to
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 is 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
5 0 0 0 0 0
that he is exempt therefrom and the basis for the alleged examption. Any violation of
APN Number
Occupancy Type
P yp
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
Trot more than five hundred dollars (S500).
31602107.00
C] es Las owner of the property, or my employwith wage as their solo compensation,
Required Inspections
will do the work• and the structure is not intended or offered for sale (Sec.7044. Business
and Professions Code: The Contractor's I Ices Law dms not apply to an owner of
q P
property who builds or improves thereon. and who doessuch work himself er tluough 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
sal .)_
❑ L as owner of the Property. am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's Ll-
cense Law does not apply to an owner of property who builds or improves thereon, and ,
who contracts for such pmjecs with a contnctor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec B & P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
i hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Conant to selr-insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
wart for which this permit is issued.
! have and will maintain Workers Companaadon Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance cubic Policy number are:
-rand
t�
Carrier. Rena. 6llC, zri°je"'" P011Cy N0.: !J ���-a��t�i�
ERT IFICATE OF EXEM FIION FROM WORKERS'
COMPENSATION INSURANCE
(This nxtiom reed not be completed if the permit is for ems hundred donate ($100)
or less.)
I certify drat in the performance of the work for which this permit is issued. I shall not
employ any person in any maancr so is to become subject to the Workers' Compenudon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cook you must
forthwith comply with such provisions or this "it shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is i construction lending agency for the performance of
the wort for which this permit is issued (Scc. 3097, Civ. C.)
Lenders Name
Lenders Address
I 1 ratify that I have read this application and state that the above information is
contcm I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize mpnesentatives of this city to enter upon the
for inspection
above -mentioned property purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j Iiabilides, judgmens, costs and expenses which may in arty way accrue against said City
' in consequence of the gnnting of this permit.
2_—e)7
I APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
Issued by: Date
SOURCE REG N .
_
Re -roofs _
Type of Roof
Q� _/ t';'!/OOlt
Signad= or ApplicanVConLr=or Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuuue 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)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes 9Tlo
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 which
emit hazardous air contaminants as dc5ned by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes IPrNo
I have mad to hazardous materials requirements under Chapter6.95 of the Califor-
nia Hcaltt & Safety Codc, sections 25505.25533 and 25534.1 understand that if tie building
does not currently have a oenam- am it is my responsibility to notify, to occupant of to
requirement& which myaatbe met prior to issuance of a ccr;rnata or
Signature of Applicant Date
j�(,� �Dq
All roof coverings to be Class'n" or better
Date '
Ow or authorized agent
I-