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090500200z C W? Q. �z UC 0 rO F h 9L CFFY OF CUPERTINO y: BUILDING DIVISION PERNIIT BUILDING ADDRESS: PE;Mrr NO. 1 INFINITE LOOP FLR 1 DPR CONSTRUCTI OWNER'S NAME: FERN9T ISSUE DATE PHONE: S A CONTROL NO. (650)474-1450 ARCHrrECTIENGINEER: BURRING PERMrriNFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I baeby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70DO) of Division 3 of dies Business and Professions Code, and my license is inrullforce andeffect. 4, COM' L TI DEMO & INSTL 717SQ NON-BEARNG ,INTERIOR Lica sic Class Uc. 0 Darc CnnUlm" WALLS& FINISHS, MINOR SPRINKLR ALTERATIONS; NO ARCHrIE(-TS DECLARATION I understand y plans shall be used as public records RE -ROOF& NO STRUCTURAL Licensed Professional OWNFR-BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors License Law for the following reason. (Section 70313, Business and Professions Cale: 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 rile a signed statement Sq. Ft. Floor Area Valuation tut he is licensed pursuant to the provisions of the Contractors Lox:nse Law (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 5 4 2 8 0 that be is exempt tbaefran and the basis for the alleged exemption. Any violation of APN Number Occupancy y pe p y -TJ Section 7031.5 by any applicant for a permit aubjcw to applicant to a civil penalty of not more too five hundred dollar (S500). 31602106.FLR1 ❑ L u owner of the property, or my employes with wages as their sale compensation, Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Cola The Contractors License Law does not apply to an ironer of property wbo builds or Improves thereon, and who does such work himself or thromgh his awn 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 that he did not build or Improve for purpose of ❑ L as owner of the property, am exclusively contracting with licensed amractaa to construct the project (Sec. 7044. Business and Professions Code:) The Cooractoes Li- cense Law does not apply to an owner of property who budlds or improves thereon, and who contracts for such projects with a contractor(s) licutsed pursuant to the Canuanor's Licese. Law. ❑ 1 am exempt under Sec. , B & P C for this reason owner Date WORICER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declaration ❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the wort for which this permit is issued_ ❑ 1 have and will maintain Workers Compensation insurance, as required by Section 3700 of the Labor Cafe, for the performance of the warn for which this permit is Issued. ' My Workers Compensation Itanuruhcc carrier apd-Policy number are: Carrier..I.1 -L ✓�� v� l % Policy No.: Lt% 41 CERTIFICATE OF EXEMMON FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed tithe permit is for am hundred dollars ($100) err Icss) , I certify that in the performance of the work for which this permit is issued, I shag not employ any person in any manner so u to become subject to the Worlmrs' Compensation Laws of Galiforrda. Date Applicant NOTICE TO APPLICANT. If, alter making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must forthwith comply With such provisions Of this permit shall be deemed revoked CONSTRUCTION LENDING AGENCY I hereby affirm that there is it construction lending agency far the performance of Uhc work for which this permit is issued (Sec. 3097, Civ. C.) ' Lenders Name Larders Address 1 certify tut 1 have read this application and state thu the above information Is cortecL 1 agree to caopiy with all City and county ordinances and stale laws mlating to building construction. and hereby authorize representatives of this city to enter upon the above-mentaned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilidea, judgments. Coss and expenses which may in any way sec= against said City in consequence of the granting of this permit l� APPLICANT UNDERSTANDS AND w L COMPLY WITH ALL N -POI Issued by: Date SOURCE ONS. �� © Re -roofs — Type of Roof Si f lirant/Contractor� D IiAZARDO ATERIALS DISCLOSURE Will the app0ant x rut !ding occupant store or handle herardous malcriai as defined by the Cupertino Mun "pal Code, Chapter 9.12. and the Health and Safety Code, Section 255324)? All roofs shall be inspected prior to any roofing material being installed. ❑Yes If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant a future building occupant use equipment or devices which emit hmuudoua air contuninants as dcri by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes 1 have mad the hasxdous marcrisis requirements under Chapter 6.95 of the Califor- nia Health & Safety Code, Sections 25505. 25533 and 25534. I Uderstand that if the building does riot currently haw: a tenant. that it is my nsibilily to notify d,e occvpanl oC Lip requiremcn must be met prior U. L of a cc ninccatc of a IX Signature of Applicant Date S S 0 All roof coverings to be C1aSs'j�'' or better eror rvcdaZenh D, V