09030075El
C
V
.7
C
F
LT•
a
J
CITY OF CUPERTINO
BUILDING DIVISION PERAUT
"u
BUILDING ADDRESS:
PERMIT NO.
21410 VAI AVE
TBD - TO BE DETERMI
OWNER'S NAME:
PERMIT ISSUE DATE
:
S A CONTROL NO.
ARCHITECT/ENGINEER
BUILDING PERMrr INFO
BLOC ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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 liccnx is
infull force and effect.
REVISE ROOF TRUSSES, STEEL BEAMS
License Class Lde. N
Date Contractor
CALC 0; OR I G# 0 8 0 3 0 019
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alTirm that I am ezempl from the Contractor's License Law for the
following mason (Section 7031Z, Business and Proressions Code: Any city or county
which requires a permit to eonstruc4 alter, improve, danolish, or repair any structure
prior to its issuance• also require the applicant for such permit to fnk a signed statement
that he is licensed pursuant to the provisions of the Contractors Liccnsc Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
0
that he is exempt therefrom and the basis for the alleged exemption. Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
APN Number
Occupancy Type
Pane Y YP
not more than five hundred dollars WO().
36205026.00
i,asownerofthe
❑ property, a my employee with wage as their sole campensadon,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Code: The Contractors License Law does Dot apply to an owner of
properly who builds or improves l u=N and who doessuch work himself or through his
own employee, provided that such improvements are not intended oroQered for sale. Ir,
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
constmet the project (Sec. 7044, Business and Professions Code:) 71he Contractors Li-
ce= Law does not apply to an owner of property who builds or Improves thereon, and,
who contracts for such projects with a co ctor(s) lia ursuanI to the contractor's
License Law.
❑ I
rrm under penalty of pe one of the following declarations:
❑ 1 have and will maintain a Certificate of Conscnl to self -insure for Wortci s Compen-
cation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the labor Code, for the performance of the wort for which this permit is issued.
'
My Worker's Compensation Insurance carries and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKFRS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for ace hundred dollars (S 100)
or lest.)
I certify that In the
forthwith comply with such provisions or this it shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance or
the work for which this permit is issued (Sec_ 3097, Civ. C.)
-
Lender's Namc
,
Lendees Address
I eertiry that 1 have read this application and state that the above information Is
correct I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representative or this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which n y way accrue against said City
in consequence of
MATE S DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.IZ and the Health and Safety
Code, Section 25532(a)? � �)No
All roofs shall be inspected prior to any roofing material being installed.
❑Yes �g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hayardons air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yp 41No
1 have read the hazardous materials requimnurnis under Chapter 6.95 or the Cali for.
nia Health & Safety Code,