09040035 CITY OF CUPERTINO
BUILDING DIVISION PERMIT + �'+TRf ��ATIQN�
BUILDING ADDRESS: PERMIT NO.
10 39 SYCAMORE DRTVF TBD - TO BE DETERMTMPD n 9-0-4-OL_3 5
OWNER'S NAME: PERMIT ISSUEDATE
ri0APUNG (Do Ki S n A
XWA CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
o p LICENSED CONTRACTOR'S DECLARATION Job Description
m I 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
Q=H in full force and a (d 8� g L ADD DE'I CHD GAZEBO, DETCHD PATIO (19 8 SQ).
v�Z License lassLic•#
F p Date i 4• O qTContractor
ARCHITECTS DECLARATION
[undcrsundin
ags�l)�1I beffd as public records
4 C in Licensed Professional
y OWNER-BUILDER DECLARATION
I hereby atTirm that 1 am exempt from the Contractors License Law for the
C p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
.4 which requires a permit to construct,alter,improve,demolish,or repair any Structure
4Z- prior to its issuance,also requires the applicant for such permit to file a signed statement
E_ that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt- (commencing with Section 7000)of Division 3 or the Business and Professions Code)or O 0
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 APN Number Occupancy Type
not mere than rive hundred dollars(M). 34257029 . 00
❑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 Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of Ll P
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.R.
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 Conuacmr'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 contractors)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Conscni to self-insure for Worker's Compen-
sa on,as provided for by Section 3700 of the Labor Code,for the performance of the
wort for which this permit is issued.
L]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 arc:
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 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 subjet o the Workcrs'Compensation
Laws of Calif mice
Applicant
NOTICE TO APPLICANT:It.after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shalt be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(x the work for which this permit is issued(Sec.3097,Civ.C.)
QLendees Name
r7Lender's Address
V 0 I certify that I have read this application and stare that the above information is
LL►-r correct.1 agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
r.o V) liabilities,judgmcns,toss and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit
APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT Issued by Date
SOURCE WULATIO
�� . 1�.� Q -J— O J Re-roofs
Signature of Applicant/Contracror Date
HAZARDOUS MATERIALS DISCLOSURE Type of R oof
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
,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑yes �(No
Will If a roof i 3 installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new n'aterials for inspection.
District?
❑Yes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safcty Codc,Sections 25505.25533 and 25534.I understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be me prior to issuance of a Certificate of Occupancy. Signature Of Applicant Date
G
All roof coverings to be Class'n"or better •�
Owner or authorixcd agent Date