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09040003OQ Z� .� t4 ter pW., az UO Ct, � OU a UZ 4 CITY OF CUPERTINO 3 ,L BUILDING DIVISION PERNIIT Pt BUILDING ADDRESS: PERMIT NO. 10552 JOHN WAY LNB CONSTRUCTION INC— 09040003 R'S NAME: PERMIT UZUE DATE PHONE: S A CONTROL NO. (415)585-3884 ARCHI'I'ECTIENGiNEER: BUILDING PERMIT Dim BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Description I hereby affirm that I am licensed under provisions of Chapter 9 (commencing .lob With Section 7000) OfDiviiq 3 of the Rosiness and finale d my license Is in full force and ec't. DEMO SFDW, 164 8 SQ FT License Class Lic. N , ' Date nl Contracor AR TiECL'S DECLAR I N I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby of rru that i am exempt from the Contractors License Law for the following reason. (Section 7M 15, Business and Professions Code: Any city or county which requires a permit to construct, alley, improve, demolish, or repair any structure prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 70D0) of Division 3 of the Business and Professions Code) or that he Is exempt therefrom and the basis for the alleged exemption Any violation of 5 0 0 0 APN Number Occupancy p y Type Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of dollars not more than five hundred (S500)- 35918007.00 L as owner of the property, or my employees with wages a thew sole compensation will do the work and the structure is not intended or offered forsale (Sec. 7044, Business Required Inspections and Professions Code: The Contractor's License Law does 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 impcmemerrts ate 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.). C] 1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec 7044. Business and Professions Code) The Contractors U- cc= Law does not apply to an owner of property who builds or improves thereon, and , who contracts for such projects with a camractor(s) licensed pursuant to the Contractors License taw. I am exempt under Sec. , B & P C for this ressoa er Date WORKERS COMPENSATION DECLARATION 1 hereby afrum under penally of perjury one of the following declarations: I have and will maintain a Certificate of Consent to seif-Insum for Woftes Compen- sation, as provided for by Section 37W of the Labor Code, for tha petfonnance of the work for which this permit is Issued. C]I have and will maintain Workers Compensation Insurance, as required by Section 370D of the Labor Code, for the performance of the work for which this permit is issued My Workers follpenUdon Itms lance carrier and Policy number art: . Carrierlyjr,-Polity No. AIiFiCA3E OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars ($100) or Icss) 1 certify that In the performance of the work for which this permit Is issued, I shall not employ arty person in any manner so as to become subject to the Workers' Compensation Laws of California. Data Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the WorluYs Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTIONLENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C-) Lenders Name — - Lenders Address I certify that I have read this application and state that the above information is correct 1 grtx o comply with all city and county ordinances and sure laws relating to building on, and hereby authorize represenutiws of this city o enter upon the above-m boned property for inspection purposes ■ o save iadcmnif and keep harmless the City of Cupertino agdrel liabilities, cad ens, toss and ex soh h may in anyway accrue against said City in cataeq the granting of peril ! APPLICA STAND A D W L COMPLY WITH ALL NON -POINT Issued by: Date `%� SOURCE U N . Re -roofs --�- - Type of Roof Signature of pplicarr C tract r Duce HAZARD U MATERIALS DISCLOSURE Will the applicant or far Ilding occupant store or handle hazardous material as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety Code, Section25532(a)7 All roofs shall be inspected prior to any roofing material being installed. use �f a-r{�ef—is-installed_without. first inspection, I agree to remove Will the applicant or future building occupant equipment or devices which -obtaining -an emit hazardous air Contaminants dcfmned by the Bay Arcs Air Quality Management all new materials for inspection. District? ❑Yee No 1 have the hazardous materials requirements under Chapter 6.95 of the Califor- nia Hcalth & Safe Cede, Sections 25505.25533 and 25534.1 understand that if time building does not current) a tenser, that t is my responsibility o notify the occupant of the requirements whi m be met to issuance of a Certificate of Occupancy. Signature of Applicant Date All roof coverings to be Classor better Owner nr aurhnm d aecnl I I k Dale "