09040120CITY OF CUPER11NU
BUILDING DIVISION PERMIT�`��'
BUILDING ADDR
10173
"WNER'S NAME:
ARCHITEC [ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fore and effpcL /Lic.V (�}-� 7 Cf
License C1> Z tz / Contractor +' t T I *r '/' "a
Date �
r
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed g'rofcssional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
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
that he is licensed pursuant to the provisions of the Contractor's license Law (Chapter 9
(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
not more than five hundred dollars (5500).
❑ 1, as owner of the property. or my employers 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 Conuactoes License Law does not apply to an owner of
property who builds or improves thereon, and who dates 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.).
❑ 1, 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 contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
�v ner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure ror Workces Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
7work "which this permit is issued.
1 haw 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 Com/o/�nsadon Insurance carrier and Policy number are:
Cartier /'T ( ) - Policy No.:
CERTIFICATE OF EXEMPTION FROM RKE S'
COMPENSATION INSURANCE
(Mis 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, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: 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 CONSTRUCTION LENDING AGENCY
(.� ►. I hereby affirm that there is a construction lending agency for the performance of
a, i the work for which this permit is issued (Sec. 3097, Civ. C.)
L17 QLender's Name
az Lendees Address
U I certify that I have read this application and state that the above information is
LL "correct. I agree to comply with all city and county ordinances and state laws relating to
C V building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
W (we) agree to save, indemnify and keep harmless the City of Cupertino against
„Hy liabilities, judgments, costs and expenses which may in any way scenic against said City
rJ Z in consequence of the g ' of this permiL
r� APPLICANT UND ANDS AN WILL COMPLY WITH ALL NON -POINT
SOURCE R ONS.
HAZARDOUS MATERIALS DISCLOSURE
Will de 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
�odc, Section 25532(a)?
❑ Yes 120�o
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
District?
❑ yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
docs not curtera �ten-��that it it my responsibility to notify the occupant of the
rcuuiremcn ch must o5'11et prior to issuance of a Certificate of Ofcupancy.
.i
408)29')-06
Job Description
REPLACE 5 WINDOWS LIKE_ FOR LIKE
iq. Ft. Floor Area
31644015.00
Issued by
Re -roofs
Type of F:oof
Occupancy Type
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof s 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 NO.
Oc)0401 20
PERMIT ISSUE DATE
2
S AAU0 09
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT
PLUMB
Job Description
REPLACE 5 WINDOWS LIKE_ FOR LIKE
iq. Ft. Floor Area
31644015.00
Issued by
Re -roofs
Type of F:oof
Occupancy Type
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof s 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