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CITY OF CUPERTINO PERMIT BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMrr NO.
10530 E ESTATES DR
TBD — TO BE DETERMINED
09090102
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
S A CONTROL NO.
ARCHr1ECT/ENGTNEER:
BUILDING PERMITTNFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I aro licensed under provisions of chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
REPAIR TO GARAGE ROOF, RMV & REPLC EXI STNG BEAM &
License ClassLic. p
Date contractor
ADD ANOTHER BEAM & ADD POSTS AS REQUIRED
ARCHrrECrS DECLARATION
I understand my plans shall be used as public records
Licensed Prufcssional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$100 O 0
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
not more than rive hundred dollars (5500).
36925028.00
1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
properly 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. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving thaz he did not build or improve for purpose of
sale.).
❑ 1, as owner of the properly, am exclusively contracting with licensed contractors to
construct the pmjecl (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.
1 am exem der Sec B & P C, or th' reason
Owner +
DECLARATION
1 hereby alarm under penalty of perjury one 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 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 are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ibis section need not be completed if the permit is for one hundred dollars(5100)
or less.)
1 emir' that in the performance of the work for which this permit is issued, 1 shall not
employ any pc n in any maMcrsq to ecome subject to ftWorl ers' C mpensation
Laws of Carlif
g th Certificate o en lion, you should
become subjec to the Workee9 Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
,
Lender's Address
1 certify that 1 have read this application and state that the above information is
'
corral 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives 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
liabilities, judgments. costs and expenses which may in any way accrue against said City
of the ting of this permit.
APPLICAeNTcUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE ROtyS.
Re -roofs
�/ -
Type of Roof / v
�/ .,]
Signature of pp rcant�—
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as derined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? _ 1
All roofs shall be inspected prior to any roofing material being installed.
ED Yes C3 No
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 whicb
emit hazardous air contaminants defined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
ED Yes o
1 have read the hazardaus 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
ro u)re nts which must be met r to issuance of a Certificate u
q
j
Signature of Applicant Date
LMS`ra
All roof coverings to be Class'n" or better
Owner Date
orauthorize agent