09010080BUILDING DIVISION PERINUT
BUILDING ADDRESS:
10100 N
OWNER'S NAME:
ARCHITECT/ENGINEER:
u p a LICENSED CONTRACTOR'S DECLARATION
°1 1 hereby aflinn that I am licensed under provisions of Chapter 9 (commencing
U with Section 7 000) of Division 3 of the Business and Professions Code, and my license is
„a, m full force and effect
Date C!)ntraOr
ARCHITECTS DEC
LARA O
r f d my plans shall be used u public records
7yU
o Licensed Professional
n y OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
y ❑ o 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 sighed statement
< that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Y(commencing with Section 70D0) of Division 3 of the Business and Pmfcssions Code) or
y that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit subject the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ I. as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered forsale (Sec. 70". Business
and Professions Cafe: The Contractors 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. ff,
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 ror purpose of
sale.).
❑ L as owner of the property, am exclusively contracting with licensed conuxiors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Date _
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insum for Workers 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 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 Workers CompensatioInsurance carrier and Policy number are:
Carrier. T P J-iIgh Policy No.:OCO3iH7 �S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (2100)
or I=)
I certify that in the performance of die work for which this permit is iasucd. I shall not
employ any person in any manner so as to become subject to the WorkeW Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after matting 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.
z M CONSTRUCTION LENDING AGENCY
(� I hereby affirm that there is a construction lending agency for the performance of
p: the work for which this permit is issued (Sec. 3097, Civ. C.)
aLenders Namc
Z Lenders Address
U Q I certify that 1 have read this application and state that the above information is
V. F correct I agree to comply with all city and county oniinances and state laws relating to
Q U building construction, and hereby authorize mpresentadves 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 ogairst
t..r fin liabilities, judgments, costs and expenses which may In any way accrue against said City
U Z In consequence e ggmdng or this permit.
'—' APPLICA ANDS ND WILL COM WITH ALL NON -POINT
SOUR ONS.
391
Si aturc of 4pliciriidronuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
m defused by the Cupertino Mumicip Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes No
WIII the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes u
I have read the hazardous materials mquinemcnls undcrCnaptcr6.95 orthe Califor-
nia Health & Safety Code, Sections 25503.25533 and 25534.1 understand that if the building
does not cure h a tenan that it is my M!%Wnaibility to notify the oeeupaM of the
requi most be prior toissuance C a Crxtifiate of Oc
41
�� o
err or &uThorizcil agent Date
(408)255-9994
PERM[[ NLI.
30"ve 5a�i.Z��
Job Description
CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB - MECH
3 PORTBL(MODULR)CLSSRMS W/TEMP DECKS, LANDNGS&
POWER 4044SQ
Ft. Floor Area
on
APN Number Occupancy Type
32631019.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date -2G�
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class'. ' or better