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09020095I td5 ;yU yO� rAu H coo K$f" rt�N z� 00 z� wy �z UO CITY OF CUPERTINO �� BUILDING DIVISION PERAM ( wk BUILDING ADDRESS. PERMIT NO. OWNER'S NAME: PMWT ISSUE DATE PHO CONTROL NO. ARCHITECT/ENGINEIiIL• BURRING PERMrrrNn ADD (1) 75KUA XFMR & RUN BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing FEEDERS PER DRAWING JobDescrilion P with Section 7000) of Division 3 of the Bush= and Professions Code, and my license is in full force and cffcci, r License Class / — / O Lie. ! Date b' _ o j Contractor - CT-S D TION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractors License Law for Um following mason. (Section 70315, Business and Professions Code: Any city or rn.ry which requires a permit to construct, alter• improve, demolish, or repair any suuctum prior to is issuance. also requires the applicant for such permit to file a signed statement that he is licensed pursuant Loft previsions of the Contractors titans Law (pspta 9 Sq. Ft. Floor Area Valuation (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 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy T} Pe P Y not more them five hundred dollars (S500). J ❑ L as owner of the property. or my employees with wags as their sole compensation. will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business and Professions Code: The Contactors License Law does net 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 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 purpow of sale.). ❑ L as owner of the property, am exclusively contracting with licensed contractors la construct the project (Sex 7044, Business and Professions Code:) The Contractors Li. cause 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 Contrxars L comae Law. ❑ 1 am exempt under Sex , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby aQlrm 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 ❑ 1 have and will maintain Wonitres Compesadon Irsurame, as required by Section 3700 of elm Labor Code• for elm performance of the work for which this permit is Issued. My Worker's Compensation Insurance carrier and Policy number am: - rf Carrier: A Ll_ I C 1)W tea(� /t .Policy No.: Z CO A26 b9l T CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed lithe permit is fa 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 manner so as to become subject to the Worimrs' Compensation Laws of Califortnfa. Data Applicant NOTICE TO APPLICANT: if• after making this Cenificae of Exemption, you should become subject to the Workers Compensation previsions of the Labor Coda, you must forthwith comply with such provisions or this peanit shall be dammed revoked CONSTRUCTION LENDING AGENCY I harcby arm that there Is a convection lending agency for the performance of the work for which this permit is issued (Sec. 3097, Clv. C.) Lenders Name Lender's Address ' 1 certify 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 stale laws resting to building construction, and bercby authorize representatives of this city to enter upon the above-memioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities.judgmonts, toss and expenses which may In carry way accrue against said City in consequence of the granting of this PaMIL APPLICANT UND ANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SO RIiGUL -roofs_- Sit&ure of Appli US MATERIALS DISCLOSURE e Type of Roof Will de applicant or fuuue building occupant store or handle hazardous material . as defined by the Cupertino Munici I Code. Chapter 9.12, and the Health and Safety code, Section25532(a)7 All roofs shall be inspected nor to an being ❑Yea No roofing material installed. P P Y g g 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 conuminans defumd by the Bay Amer Air Quakily Managcmat all new materials for inspection. Dsoct7 ❑ Yes No 1 have read the hLTxdous materials mqufm=ns under chapter &95 of tins Califor- nia health & Safety Code, Sections 15305.25533 and 15534. I understand the tithe building dap not I tly have a t. tar It s my responsibilily.to notify the occupant of the roguire whichmatsbe I oressuw=ofaCrnifrcamof Signature of Applicant Date Z6ri=d '