09040072BUILDING DIVISION PERIVHT
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10201 BUBB RD
OWNER'S NAME:
ARCHn-ECr/ENGINEER:
I hereby affirm that I am licensed undo provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my liieerst: is
in full force and effect -
License Class Lic. s
Date Contractor
ARCHITECTS DECLARATION
I understand my plus shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Cock: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any Wwum
prior to its issuance. also requires the applicant for such permit to file a signed sulemcot
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 B tartness and Professions Cade) or
that be 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 penally of
not moss than five hundred dollars (S500).
❑ 1, as owner of the property, or toy employees with wages as their sole enmperuMdon.
win do the wort, wA the suucmm is not intended or offered for sale (Sec. 7044, B uminess
and Professions Coder The Conuactors L.irznse Law does not apply to an owner of
property who builds or Improves thereon, and who does such work himself at through his
own empkryem provided that such improvements are not Intended or offered rot axle. If.
however, the building or improvcmard. is sold within one year of completion. time owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.)_
�I 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project. (Sec. 7044. Business and Professions Code:) The Contras ar'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 Contractors
License Law.
❑ 1 am exempt urid, 8 B & P C for this reason
�w�rz ��-
...._...•Wmtyjm1S COMPENSA CLARAnON
I hereby affirm under pemalty of perjury arc of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, 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 Workers Compemallon Insurance, az required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy Nm:
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(this section reed not be completed if the permit is for one hundred doll= (SI01n
or less.)
1 certify that In the performance of the work for which this permit is issued. 1 sham not
employ any person in any r az to brrumms�ubicct to the Workers' Compensation
Laws of Calif rp Dater �GL7� -�
AppuTN& Ll making this Certificate of Facmption. you should
become subj= to the Workers Compensation provisions of the Labor Code. you must
fonbwitb comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm dat there is a construction tending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C-)
Lenders Name
Lenders Address
. I testify that I have read this applicadon and state tiers the above information Ls
cormrL I agree to comply with all city and county online tcea and ante laws relating to
building construction, and hereby authosire represents ives of 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
Iiabilkdes, Judgments. costs and expenses which may in any way acme against said City
in consequence of the granting of this permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULKITON3\
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or rumare building omlpant store or handle hrardous material
as detlned by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
:ode. Section 25532(a)7 v
Will the applicant or rotate building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management
Irict7
❑ Yes �o
1 have read the hazardous materials requirements under Chapter 05 of the Califor-
uhh & Safety Code, Sections 2.5505, 25533 and 73534. I understand that If the building
ut currently have a tenan, Use it is Mllty to notify the occupant of der:
�menia-whiek-m be met prior t issuance of cnificatc of Occupang. I
err outaut om��anem Datc�CDLa�tcc '
BUBB PARTNERS
PERMIT WIDE DATE
Job Description
CONTROL NO.
BUILDING PHRMrr INFO
ELECT PLUMB MECH
INSTALL SURFACE MOUNT PLUMBING FOR COMPRESSED
GAS -ARGON & NITROGEN. MFG SPECS FOR PIPE
CONNECTORS & MOUNTIN HARDWARE INCLUDED.
Sq. Ft. Floor Area Valuation
$2000
APN Number Occupancy Type
35720006.GAS
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date �- 2-or Z_"�;
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'A!' or better