09040056BUILDING DIVISION PERMIT
BUILDING ADDR
19620
OWNER'S NAME:
ARCHITECT/ENGINEER.
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Divislon 3 of tha Business and Professions Code, and MY license Is .
in full form and eQ yz u g 3�
Date Con DEC N - G
DECLARATION
LARATION
I understand my plans shall be used as public records
U
t; Licensed Professional
y l OWNER -BUILDER DECLARATION
2 I hereby affirm that I antexempt from the Contractors License Law for the
q following reason. (Section 70313, Business and Profassions Code: Any city or county
$ which requires a permit to conmct,'alter, improve, demolish, or repair any structure
Z' prior to Ls issuance, also requires the applicant for such permit to file a signed statement
s that he Is licensed pursuant to the previsions of the ContracLoes Licenso Law (Chapter 9
r (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
.. that he is exempt tharefWal 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 mors than five hundred dollars (5900).
0 I. u owner of the property, Of my employees with wages u their sola compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions, Coda The Contractors License Law does 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 sola 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.).
0 I; u owner of the property, am exclusively contracting with 0cansed contrsctors to
construct the project (Sec. 7044, Business and Professions Code:) 77W Contractor's LI-
canse Law does not apply to an owner of property who builds or improves themon, and ,
who contracts for such projects with a cetracntmctor(s) licensed pursuant to the Contors
License Law.
0 I am exempt under Sec, B, P C for this mason
408)986-871
PERMIT NO.
PERMIT ISSUE DATE
Job Description
REV, GAS METER HANDRAIL; ORIG 0706012.8;
36906010.00
Area
Required Inspections
Occupancy
I have mad the hazardous materials mquimmens under Chapter 6.95 of the Califor-
nia Health &Safety Coda, Sections 25505, 25533 and 25534.1 undersand That if the building
dee not current) `have a reriant, that it is my responsibility to notify Use occupant of the
require ns w '6h must be met prior to issuance of a Certificate of o,147( Signature of Applicant Date .
All roof coverings to be Class 'A" or better
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Owns Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 l have and will maintain a certificate of Consent to selfdnsum for Worker's Compen-
sadon, u provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 I haw and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Coda, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier.'. w IG ldeMilit7 Policy No,; 2 2029 15
WORKERS'
Lom CERTIFICATE OF EXEMPTION FROM
COMPENSATION INSURANCE
t:G �r�h1uV-1 r0L
Mis (I on need not be completed if the permit is for one hundred dollars ($100)
or less)
I certify that in the performance bf the work for which this permit is issued, I shall not
'
employ any person in any mannarso as to become subject to the Workers' Compensation
Laws of CaArom a. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Componsition provisions of the Labor Code, you must
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forthwith comply with such provisions or this porm(I shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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1 hereby a[fmtm that theme is a construction lending agency for the performance of
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the work for which this permit is Issued (Sea. 3097, Civ. C.)
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Lenders Nano
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Landers Address
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' I certify that I have read this application and sate that the above information Is
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cormcL I agree to comply with all city and county ordinances and sate law's relating to
building construction, and hereby authodm representative of this city to enter upon the
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above-mentioned property for inspection purposes
(Wo) agree to save, indemnify and keep harmless tie City of Cupertino against
in
CityIn
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liabilities, judgments, costs and expenses which may any way accrue against said
the thisD
couence of
NDS ANof
APPLLCC UNDERSTAMIL
WILL COMPLY WITH ALL NON -POINT.
Issued by:
SOUR EGU TIONS.
' r/i 110
Re -roofs
Slgtiature of Applicant/Contmtor Date
HAZARDOUS MATERIALS DISCLOSURE
^.
Type of Roof
Will the applicant or future building oceupantstom orhandle hwardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(,)7
All roofs shall be inspected prior to any roofing material be insj
'�
0 yes No
If a roof is installed without first obtaining an inspection, I agree t(
Will the applicant or stare building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
O Yes '46Np
I have mad the hazardous materials mquimmens under Chapter 6.95 of the Califor-
nia Health &Safety Coda, Sections 25505, 25533 and 25534.1 undersand That if the building
dee not current) `have a reriant, that it is my responsibility to notify Use occupant of the
require ns w '6h must be met prior to issuance of a Certificate of o,147( Signature of Applicant Date .
All roof coverings to be Class 'A" or better
n...-.. ... ..,.1......,,.d ..,.,:,
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