09020030 CITY OF CUPERTINO 77,
y�'Y
BUILDING DIVISION PERMIT hnb�[ �{11tiNh' fxTAaxl`
BUILDING ADDRESS: - PER Mrr NO.
OWNER'S NAME: INC PERMIT ISSUE DATE
PHO S Afttt CONTROL N0.
408 379-5500
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l o 0 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z� with Section 7000)of Di on 3 of the Business and Professions Code,and my license is
!may in casc ce ndoffect. 2l� Cl-7`� COMM'L TI, INSTALL 2 CHAMBER ROOMS, INCL
ucense a Llc,s
�t o Dale Contracmr L I ELECTRICAL, MECHANICAL, & STRUCTURAL (1015 SQ) ,
e ARCHITECT-S DECLARATION
5w 1 understand my plans shall be used as public records NO RE—ROOF.
c.
LL� Licensed Professional
o
0 OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
:❑0 following reason.(Section 7031.5,Business and Professions Code:Any city or county
t m which requires a permit to construct.alter,improve,demolish,or repair any structure
z prior to its issuance,also requires the applicant for such permit to file a signed statement
h=o that he is licensed pursuant to the provisions of the Conuactoes License law(Chapter 9 Sq.Ft.Floor Area Valuation
F- (commenting with Section 7000)of Division 3 of the Business and Professions Cade)or
dust he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703"by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollar(5500).
❑T,as owner of the property,or my employees with wages as their sole compensation, �16 0 6 0 4 6 .F LR 2
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Cede The Contactors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended oroffemd forsale.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 rot build or improve for purpose of
sale.).
❑L as owner of the property,am exclusively contracting with 5c msed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contrb=e3 I.I.
conic 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 Sec B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to selGinsure 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.
❑I have and will maintain Workers 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. f•C0nc n i`C.jrc rPolicyNo.: Ckl(3Z"L-Ply
CERTIFICATE OF EXEMPTION FROM W OP KERS'
COMPENSATION INSURANCE
Cfhis section need not be completed If the permit is for one hundred dollars(SI00)
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 Workers Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
7 O
CONSTRUCTION LENDING AGENCY
I hereby afnrm that there is p construction lending agency for the performance of
Y.> the work for which this permit Is issued(Sec.3097,Civ.C-)
fin~- Lenders Name
z Lenders Address
Q I cartify that I 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 representauvu of this city to enter upon the
W above-mendoncd property for inspection purposes.
y (We)agree to save,indemnify and keep harmless the City of Cupertino against
Cn liabilides,judgments,costs and expenses which may in any way accrue against said City
7 in PP
of the granting of tlds permit. 3 (J q
h� AA UNDERSTANDS WILL COMPLY WITH All O -POINT Issued by: Date /
CE REGULATIONS.
, `7 Re-roofs
Si of Applicant/Contactor I Dale —
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 roofs shall be inspected prior to any roofing material being installed.
C,Yes �p Ne
Will the applicant or future building occupant use equipment or devices which r 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
I have mad the hazardous maicrials requirements under Chapter 6.95of Use Califor-
nice Health&Saf t Code,Sections 25505.25533 and 25534.1 understand dm If the building
does not U haw a tenant.that[t u res briny to noufy tiro oaupan of due
mquirem to chmuubcmetpriorto- acertifieatcerOeeu Signature of Applicant Date
Owner .cdagcnt Dato All roof coverings to be Class"A"or better