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09040047CY OF CUPERIILYO BUILDING DIVISION PEPMT BUILDING ADDRESS: 10210 L OWNER'S NAME. PHONE: ARCHITECrfENGINEER: u O p LICENSED CONTRACTOR'S DECLARATION U U 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing - Z,with Section 7000) of Division 3 of the Business and Professions Code, and my license is H in full force and cffecL ? License Class Lic. p o Date Contractor LQ ARCHITECT'S DECLARATION ce < I understand my plans shall be used as public records Dwd i n, t; Licensed Professional U0, y -4 OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the p O following reason. (Section 7031.5, Business and Professions Code: Any city or county K ,00 E which requires a permit to construct, alter, improve, demolish, or repair any structure Z y prior to its issuance, also requires the applicant for such permit to rile a signed statement E _ that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Y t- (commencing with Section 7000) of Division 3 of the Business and Professions Code) of 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 not more than five hundred dollars (5500). ❑ 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. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or through his awn 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.). [11, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044. Business and Professions Cade:) The Contractor's Li. cense law docs 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 Contractor's License Law. ❑ 1 am exempt under Ser, , B & P C for th's reason Owner �i'�Wy Date WO ER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the fallowing declarations: ❑ I have and will maintain a Certificate of Consent to self -insure far Worker's Compen- sation, as provided for by Section 3700 of the Labor Cade, 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 Cade, for the performance of the work forwhich this permit is issued. My Worker's Compensation Insurance artier and Policy number are: Job Description ADD 3 OUTLTS,RPLC 8-2 PRNRS W/PRONG GRNDED(11 TOTL) ANCHR,REWIRE INSLT&STUCO FRNT WL(A—B ON PLAN219SQ Sq, Ft. Floor Area 4 Valuation APN Number Occupancy Type 34214012.00 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 cenify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so became subject to the Workers' Compensation Laws of Cal(f2i n - - Applicant DVA NOTICE PPLICANI If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the labor Code you must .J Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONsmucnON LENDING AGENCY Fr W 1 hereby affirm that there is a construction lending agency for the performance of {l: > the work for which this permit is issued (Sec. 3097, Civ. C.) aQ Lender's Name Z Lender's Address U 0 I certify that I have read this application and state that the above information is VZ — correct. I agree to comply with all city and county ordinances and stale laws relating to 0 V building construction, and hereby authorize representatives of this city to enter upon the Uahovc-mentioned properly for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilides,judgmcnts, casts and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. ►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: .Tgffmtrte of KpplTcartf/Cddlraclor r ' / Dale 5PHAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by Elie Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipmentor devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management. District? ❑ Yes ❑ No 1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Cade, Sections 25505, 25533 and 25534. I understand that if the building docs not currently have a ant, that it is my responsibility to notify the occupant of the reggirf5 gnts whigjt must to t prior to issuance of a Certificate of Occupangy. or authorized aeent / r Date Re -roofs Type of Roof Required Inspections Date 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 PERMIT N0. PERMIT ISSUE DATE S A CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH Job Description ADD 3 OUTLTS,RPLC 8-2 PRNRS W/PRONG GRNDED(11 TOTL) ANCHR,REWIRE INSLT&STUCO FRNT WL(A—B ON PLAN219SQ Sq, Ft. Floor Area 4 Valuation APN Number Occupancy Type 34214012.00 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 cenify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so became subject to the Workers' Compensation Laws of Cal(f2i n - - Applicant DVA NOTICE PPLICANI If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the labor Code you must .J Z forthwith comply with such provisions or this permit shall be deemed revoked. Z O CONsmucnON LENDING AGENCY Fr W 1 hereby affirm that there is a construction lending agency for the performance of {l: > the work for which this permit is issued (Sec. 3097, Civ. C.) aQ Lender's Name Z Lender's Address U 0 I certify that I have read this application and state that the above information is VZ — correct. I agree to comply with all city and county ordinances and stale laws relating to 0 V building construction, and hereby authorize representatives of this city to enter upon the Uahovc-mentioned properly for inspection purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilides,judgmcnts, casts and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. ►- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: .Tgffmtrte of KpplTcartf/Cddlraclor r ' / Dale 5PHAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by Elie Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes ❑ No Will the applicant or future building occupant use equipmentor devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management. District? ❑ Yes ❑ No 1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Cade, Sections 25505, 25533 and 25534. I understand that if the building docs not currently have a ant, that it is my responsibility to notify the occupant of the reggirf5 gnts whigjt must to t prior to issuance of a Certificate of Occupangy. or authorized aeent / r Date Re -roofs Type of Roof Required Inspections Date 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