09040119 CITY OF CUPERTIIVO Y•v ��.
BUILDING DIVISION PERMIT 2_1 «
c ctY`�.
BUILDING ADDRESS: PERMIT NO.
22051 HIBISCUS DR ORR CH ISTIAN
OWNER'S NAME: ET PF.RMrr ISSUE DATE
PHO SA CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
KITCHEN REMODEL O O O 0
10 p LICENSED CONTRACTOR'S DECLARATION
I bcreby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�<y in full force and effect
j Z License Class LJc.0 .
Dam Contractor
e ARCHITECT'S DECLARATION
G I understand my plans shall he used as public records
6
O Licensed Professional
OWNER-BUILDER DECLARATION
i hereby affirm that I am exempt from the Contractor's License Law for the
C OO following reason(Section 7031.5,Business and Professions Code:Any city or county
<m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
u Z y prior to its issuance,also mquirts the applicant for such permit to rile a signed statement
2 7^�Cc< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
2 F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
4 that he is exempt therefrom and the basis for the alleged exemption Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy e
not more than rive hundred dollars(S50tn. P y Typ
❑1,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
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves the con,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 owner- .
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner or the property,am exclusively contracting with licensed contactors to
concoct the pmject(Sec.7044,Business and Professions Code:)The Coomwes LJ-
ceese Law does not apply to an owner of property who builds or improves t emon,and.
who contracts for such projects with a contactor(s)licensed pursuant to the Contactors
License Law.
❑I arm ex d Sec ,B&L,P(C for this reason
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to elf-inswe 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 art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed 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 person in anyyr� to berq)npyubjecl to the Workcrs'Compensation
Laws of Cali a � 7 —
Applicam �2
NOTICE LJCANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compem-Arlon provisions of the Labor Code,you must
=O forthwith comply with such provisions or this permit shall be deemed revoked"^ CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
3i> the work for which this permit is issued(See.3097,Civ.C.)
Q Lender's Namc ,
jz Lenders Address
;)Q I certify that 1 have read this application and sate that the above information is
correct.I agree to comply with all city and county ordinances and sate laws relating to
p` building concoction,and hereby authorize representatives of this city to enter upon the
v above-mentioned property for inspection purposes.
ya (We)agree to save,indemnify and keep harmless the City of Cupertino against
L�t] liabilities,judgments,costs and expenses which may in any way accrue against said City
;)7 in consequence of the granting of this permlL
APPLICAKT-UNIDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date z tj
SOUR G t ONS. / �t
L=2 Re-roofs
Signature of Applicant/Contractor Date —
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.Section25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
J� 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 de0ned by the Bay Ares Air Quality Management all new materials for inspection.
District?
❑Yes Dfo
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cahfor- -
nia Health&Safety Codc,Sections 25505,25533 and 25534.1 understand that if IM building
does not currently se a to nan4 that it is my responsibility to notify the occupant of the
• t,s<bcm ragaelprior� of�Lam issuance reof Signature of Applicant
Dale
O car authorized agent Date'
All roof coverings to be Class'n"or better