09050060 77777777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT I0. .� } TIQ�1 '
PERMIT NO.
BUILDING ADDRESS:
6716 CLIFFORD DR TBD — TU BE DET
PERMIT ISSUE DATE
VNER'S NAME:
A CONTROL NO.
PHONE:
BUILDING PERMIT INFO
ARCHPIEC(ENGINEER: BLDG ELECT PLUMB MECH
v p p LICENSED CONTRACTOR'S DECLARATION Job Description
U C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z trot with Section 7000)of Division 3 of the Business and Professions Code.and my license is ADD 9 'X'-4 ' PATI 0 C OVER (METAL) (12 6 SQ)
n'4 y in full fore and effect 6161576
gi Z License Claw
a Dam /o C actor Goyc /�/jtr�7/t c BSL #14047 CURRENT THRU 12/31/9
ARCHITECTS DECLARATION
C< I understand my plans shall be used as public records
DWU
Licensed Professional
CH
OWNER-BUILDER DECLARATION
`2 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following reason.(Section 7031.5,Business and Professions Code:Any city or county
K Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
y—y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
?< that he is licensed pursuant to the previsions of the Contractor's License Law(Chapter 9 Sq.
x F C (commencing with Section 7000)of Division 3 othc Business and ProfessionsCodc)or $900
y 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
WE more than rive hundred dollars(M). 3692704L . 00
0 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 oroffered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law dors 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 We.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,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's u.
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.
0 I am exempt under Sec .B&P C for this reason
sner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I hsae 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.
ly I have and will maintain Workers Compensation Insurance,as required by Section
5700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation►nsuranct carrier and Policy number am:
Cartier 11Cd� l�RIieNA L_Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not be completed if the permit is for one hundred dollars($100)
or ICas.)
1 certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
App=1
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z, CONSTRUCTION LENDING AGENCY
(.-d rte. I hereby affirm that there is a construction lending agency for the performance of
C4> the work for which this permit is issued(Sec.3097,Civ.C.) ,
W Q Lendces Name
Az Lcndees Address
I certify that I have read this application and state that the above information is
LUL correct.I agree to comply with all city and county ordinances and state laws relating to
0U building construction,and hereby authorize representatives of this city to enter upon the
Wabove-mentioned property for inspection purposes.
15r (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL NON-POINT Issued by:
SOURCE REGULATIONS.
Re-roofs
Signature ofAppr ontraclor Dam T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ide.Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
[3 Yes �RNo
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new i naterials for inspection.
District?
0 Yes NO
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the Date
requirements which must be met ' r to'ssuance of a Certificated Occup S ignatur:of Applicant
141 _ /9/a i All roof coverings to be Class'�W'or better
Owns ed agent Datc