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09030040 CITY OF CUPERTINO �t -pT BUILDING DIVISION PERMIT PERMIT NO. BUILDING ADDRESS: 1 1 ST Fq AVE TBD - PO B PERMIT ISSUE DATE OWNER'S NAME: SA Aip CONTROL NO. .10 BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH REMODEL 200 SQ FT TO 2 o o LICENSED CONTRACTOR'S DECLARATION BATH NON—STRUCTURAL Job Description m C I hereby affirm that I am licensed under provisions of Chapter 9(commencing Zm with Section 7000)of Division 3 of the Business and Professions Code,and my license is y in full force and effect v�Z License Class Lic•N n E-0 Date Contractor ARCHITECTS DECLARATION < I understand my plans shall be used as public records X96 L O rn Licensed Professional rn� OWNER-BUILDER DECLARATION I hereby allirm that I am exempt from the Contractor's License Law for the a O 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 its issuance,also requires the applicant for such permit to file a signed statement Ft,Floor Area Valuation Z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq xH (commencing with Section 7000)of Division 3 of the Business and Professions 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 subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(5500). [11.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 for sale(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of Q p 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.). ❑I•as owner of the property.am exclusively contracting with licensed contractors to construct the project(Sec.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 Convector's License Law. B&P C for th' reason ❑1 am t unser- Owner �� Date WORK ' CO ENSATION DECLARATION I hereby affirm under pe of perjury one of the following decl ns: ❑1 have and will maintain a Certificate of Consent to self-insure 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 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 am: 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 pc an anncr so to bccom bjcct to the Workcrs'Compensation 0� C91 Laws of califoroia tc Applit:ant NOTICE TO APPLICANT:If,aftc aki IpAis Cern icatc of Exemption,you should become subject to the Worker's Com -provisions of the Labor Code,you mutt Oforthwith comply with such provisions oNhis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY F~-r I hereby affirm that there is a consuuctian lending agency for the performance of the work for which this permit is issued(Sec.3097,Civ.C.) W A Lender's Name Z Lcndees Address U 0 1 certify that i have read this application and state that the above information is V. correct 1 agree to comply with all city and county ordinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the U above-mentioned property for inspection purposes. (Wc)agree to save,indemnify and keep harmless the City of Cupertino against CA liabilities,judgments,costs and expenses which may in any way accrue against said City U z in co a of the granting of this permit Date APPL A U DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b'/: SOUR UL ONS. 3 o a Re Signa ­54ture -- SignatureofApplicanVCon for Datc HAZAR Us ALS DISCLOSURE Type of:goof Will the applicant or Tut ilding occupant store or handle hazardous ma "al as defined by the Cupertino Munici al Code.Chapter 9.12,and the Health and Safety Code.Section 25532(a)? All roof:,shall be inspected prior to any roofing material being installed. C]Yes 0No TITT'"' 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 defined by the Bay Area Air Quality Management all new I naterials for inspection. District? ❑Yes fJl No 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia th&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building docs t c nd ave a tenant that it is my responsibility to notify the occupant of the requirem which c met prior to issuance of a Ccrtific tc of Occu ancy. Sign of Applicant Date -) D Cl rrr, ar All roof coverings to be Class J�. or better Owner or authorized agent re