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09040091CITY OF CUPEKTINU BUILDING DIVISION PERA41T BUILDING ADDR 19620 OWNER'S NAME: ARCHITECUENGINEER: 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 n full force and cffe� ¢! G3 p :lccnsc Class U.. N Dau; Contractor AitcHrrEcrS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law far the following reason. (Section 7031.5, Business and Profusions 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 far such permit to file a signed statement that he is licensed pursuant to the previsions of the Contractor's License Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Profusions 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). ❑ 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 for sale (Sec. 7044, Business and Professions Code: The Contracto(s License Law docs not 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 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.). ( I, 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 Seo. , B & P C for this reason Owner Dale WORKER'S COMPENSATION DECLARATION I hereby affirm under penally 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. ❑ 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 Workers Compensation Insurance carrier and Policy number am: Carrier.Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($I00) 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 asto become subject io the Workers' Compensation Laws of Califarnia. Date _-11 Applicantif c NOTICE TO APPLICANT: If, after making this Certificate of Ex�ett prion, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lenders Name Lenders Address I certify that I have read this application and slate that the above information is correct. l agme to comply with all city and county ordinances and state laws relating to building construction. and hereby authorize representatives or this city to enter upon the above-mentioned property for inspection pugww& (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE aL S. Signature of Applicani/Contractor Dat_ HAZARDOUS MATERIALS DISCLOSURE . i Will the applicant or future building occupanlstore or handle havardous material as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety Code, Section 25532(a)? ❑ Yes 'IANo 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 KNo I have mad the hazardous materials eequimmen is under Chapter 6.95 of the Cal ifor. nia Health & Safety Code, Sections 25505,25533 and 25534.1understand that lfthe building docs not currently have a tenant that it is my responsibility to notify the occupant of the requirements must be m dor to issuance a Certificate of Occupancy. ,r or authorized agent Data WANNVA INSTALL ILLUMINATED LETTER SIGN Ft. Floor Area APN p Re -roofs Type of Roof Job Description Required Inspections Occupancy 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 NO. PERMIT ISSUE DATE SA CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB MECH :HANNEL C� CI D C7 Job Description Required Inspections Occupancy 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