09020088CITY OF CUPERTINO
BUILDING DIVISION PERAUT
..
BUILDING ADDRESS:
PERMrr NO.
18810 NEWSOM AVE
TBD — TO BE DETERMINED
0902ongg
OWNER'S NAME.
PERMIT ISSUE DATE
CONTROL NO.
ARCHLTECT/ENGINEER:
BUILDING PERMrrINFO
BL.DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hecby affirm that I am licensed under provisions of Chapter (commencing
3 prim Business and Prarasioma cede. and my licenac u
in ullse� and of �Divisipn
t.
ADDITION 3 8 8 ' STUDY, 2 BEDRMS , 1 BATHRM , 2
Lk.
Daleensoaa:a con
SKYLIGHTS. REMODEL 740' 2 BEDRMS,HALLWAY & GARAGE
( understand my plans a used ARCHITECT'S
be uses asETION publicCArecorrdds
REROOF 18 SQS .
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason_ (Section 7031.5, Business and Professions Code: Any city or campy
which requires a permit to canstrmcL altar, improve, ddmmlLsh, or repair say SWtture
prior 10 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 provisions of the Contractor's Licenx Law (Chapter 9
Sq.
(commencing with Section 70()0) of Division 3 of the Business and Proressions Code) or
5 0 0 0 0
that he is exempt therefrom and the bags for the alleged exemption. Any vloladon or
Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number Occupancy Type
not more than five hundred dollars (ssoo).
37530016 .00
❑ L, as owner of tho property, or my employees with wages as their sole compeuadon,
will do the work, and the tmucttrte is not Intended or offered for Sale (see. 7044. Business
Required Inspections
and Professions Code Ilia Comrsiewes License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himselror through his
own employees. provided dW 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
sak.).
❑ 1. as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Coda) 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 eontr-aetar(s) licensed pursuant to the Contractor's
License Law.
❑ I am excrM wi , B& P C f thy a
Owner �-- Date � 0
WORKER'S CPMPFNSATION DECLARATION
I hereby affirm ender penalty of perjury am of the following declarations:
❑ I hive and will maintain a Certificate of Consent to self -Insure for Warker'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.
❑ I 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 au Compensation Inruice carrier and Policy number are:
C nice-.. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Olds section need not be completed if the permit is for one hundred dollars (f 10D)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
-
employ any person in any manner so 3t b b subject to the Worisers' ypemadon
Laws of Califorma.
�• '---�-
NOTICE TO APPLICANT. If, after mall g this Certificate of Exemptiok you should
become subject to the Workds Compensation provisions of the Labor Code, you mud
forthwith comply with sucb provisions or this permit shall be domed revol¢d
CONSTRUCTION LENDING AGENCY
I hereby affirm dot there is a construction lending agency for the performance of
the work for which this permit is sued (sec. 3097. Civ. C.)
Lender's Name
,
Lender's Address
I certify that I have read this application and sate due the above Information is
correct. I agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authorize represenatives of this city to cater upon the
above -mentioned property for Inspection purposes.
.
(We) agree to save, indemnify and keep harm lest tin City of Cupertino against
liabifltles, judgments, costs and expenses which may In any way accrue against said City
in consequence of the granting of ads permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
q
Issued by: Date
SOURCE
D�
HAZA)MUS MATERIALS DISCLOSURE
Type of Roof
Will the applieam or future building occupant store or handle hendous mammal
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section 25532(.)±
All roofs shall be inspected prior to any roofing material being installed.
❑ Yea C4Nb
yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use egtripmeot or devices which
emit hazardous air cataminanls as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
[]Yca
I have road the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534. I understand dot if the building
does not currently have a taunt, that it is my responsibility to notify the occupant of the
�All
Signature of Applicant Date
agent
roof coverings to be Class'%¢'' or betterheriud
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