09030050CITY OF CUPERTINO
PERMIT����fi
BUILDING DIVISION
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BUILDING ADDRESS:
PERMIT NO.
633 PHIL CT
ROBERT.0 BARR CO
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7 I PAB13e AVE
5 A CONTROL NO.
408749c,929
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fora and effect.
REV(OR(; # 0 9 0 3 0 0 5 0) STRCTRL RF/WALL DETAIL&REVI S
D Class CC.00n actor
FNDTN ISLB &EXTNG FNDTN TIE—IN &ELECTRCL PLUG
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
LO C S & C F ; I LNG LITE S
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
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Contractor's License (Chapter
(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
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
3754201.9 .00
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 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
License Law.
❑ 1 am exeml.nd Se , B& P 3 1 C f r this n
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workees Compcn-
sation, 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 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
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 mannp s W eco c jecI to the Workc ' Compensation
Laws of California Date
Applin
should
become subject to the Worker's 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
?"
Lendees Address
I certify that 1 have read this application and state that the above information is
" correct. I agree to comply with all city and county ordinances and state 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
7 liabilities, judgments, costs and expenses which may in any way acerin against said City
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y in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR EG LA ONS. /Z o q
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Issued b) : Date
Re -roofs
icanfSignuue
store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
-ode, Section 25532(a)7
Yes $ No
All roofs shall be inspected prior to any roofing material being installed.
❑
If a roof .s 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 defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
Cl Yes 2(N.
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not u ntly have a tenant, that it is my responsibility to notify the occupant of the
require w ' h rpust be a oto iss of a Ccrtifuau f Oc p
q ' �' C.� �' �
Signature of Applicant ate
3 !�
�^All
roof coverings to be Class 'A" or better
Owner Dau