09020096boo
' l=v12
2
#�U
y Cn
5mC�
ra_y
zr
y C
g59
0 :2
zC
W?
UC
4.
o t
Fo
rr co
U�
CITY OF CUPERTINO ��T7� ��g-r��
r
�z
BUILDING DIVISION PE1tLyJ11
q
BUILDING ADDRESS:
PERMrr NO.
OWNER'S NAME.
PERMrr ISSUE DATE
'
A CONTROL 10.
650 813-999
ARCHr EC'r(ENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CON TRACMR's DECLARATbON
Job Description
1 hereby affirm that 1 am Ilmnaed under provisions of Chapter 9 (commencing
with Section 7000) o(Divislon 3 of the Business and Pro(etao s license is
�my
in full force and err 6
—!D aJc.0
RUN . FEEDER ONLY TO A J,—BOX ON CEILING
License class
Date �_ i Contractor
ARCHrrECrS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors Lkcnse Law for the
following mason. (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 issusnte, also requires the applicant for such permit to rile a signed statement
Contractor's Ucense Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 70011) of Division 3 of the Business and Prufrsiona Code) or
that he is exempt therefrom and the basis for the alloged 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
root more than five hundred dollars (SYM
36955082 . 10
❑ L as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work and the structure is Trot intended or offered for sale (sec- Mona, Business
and Professions Code The Contractorcense s LiLaw does net 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 art: not Intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owrrer-
bu0mr will have der burden of proving that he did not build or improve for purpose of
sale.).
❑ L as owner of the property, am cxdusively contracting with licensed contnictors to
construct the project (Sec 7044, Business and Professions Code:) The Contactors L-
eone Law does not apply to an comer of property who builds or improves thereon, Lad.
who conuscts for such projects with a contractor(s) licensed pursuant to ibe Cantraetofs
Licea4 Law.
❑ 1 am exempt under Sec , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of die following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workees Compen-
sation, as provided for by Section 3700 of the arbor Cade, 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 Workees Compom ad unrrcc carrier and Policy number am:
Carrier Policy No.;
CE 7E OF CEM ON FROM ORKERT
COMPENSATION INSURANCE
(rhit section need not be completed if the permit Is for one hundred dollars ($100)
or lest)
I certify that in the performance of the work for which this permit is issued 1 shall not
employ any person in any manner so as to become subject to the Workers' Compwadon
Laws of California. Duc
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions or the Labor Cade, you mast
' forthwith comply with such provisions or this permit shall be deemed revoked.
1
' CONSTRUCTION LENDING AGENCY
1 hereby silim that there Is at construction lending agency for the performanceof
the work for which this perch Is issued (Sec. 3097, Civ. C.)
Lender's Name
L.ende's Address
j 1 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 suite Laws relating to
building construction, and hereby authorize mpmsentaiives 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
r
I liabilities, judgments, costs and expenses which may in my way acme against said City
in co of the granting of this permit.
APPLI NT
DLsCL.ObUlui ato
Will oho applicant or Runic building occupant store or handle fuiardn n m-ter;,l
as defined by the Cupertino Mu Code. Chapter 9.12. and the Health and Safety
Code, Section25332(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes No
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 cenaminann fined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes No
I read the hanrdaumaicrialsrequirements under Chaptcr6.93o(thcCalifor-
nia Hcai k Safety C ons n-'C5, 25533 and 25534. I uideNand the if the building
don not ntly