09030222CITY OF CUPERTINO
BUILDING DIVISION PERAUT
BUILDING ADDRESS:
PERMrr NO.
OWNER'S NAME:
ARCHITEC 1F_NGINEFR:
C p LICENSED CONTRACTOR'S DECLARATION
U 1 hereby affirm dot I am licensed under provisions of Chapter 9 (commencing
Z with Sidon 7000) of taion 3 of the Huainan and Profeidom Code, d my license is
in full force and effect I
ja License Class nLle. +►
3 Date Contractor
CHECT'S DECLARA �J V
I understand my plans shall be used as public records I
0yV
m F Licensed Professional
y OWNER -BUILDER DECLARATION
1 hereby allirm that 1 am e:=rope from to Contractor's License Law for the
O G following reason (Section 7031.5. Business and Professions Code: Any city or courtly
1 $ V which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to is issuance, also requires Ibc applicant for such permit w file a signed osic cm
Ndrat he is licensed pursuant to the provisions o< tie Contractor's License Law (Chapter 9
.. (commencing with Section 7000) of Division 3 of the Businessland Professioru Code) or
y that be is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 703" by any applkwt for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SSW).
❑ L as owner of the property, or my employes with wages as Weir sole compensation,
will do the wort, and the structure is not intended or offered for sale (Six. 70W, Business
and Profeamnna Code: The Conuaewls 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 improvements are not intended or offered for sale. B.
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 ).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
corms ct the pmjea (Sec. 7044, Business and Professors Code:) The Contractor's Li-
ccnae Law does mot apply to an owner of property who builds or improves themon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
Licetve Law.
❑ 1 am exempt under See, B & P C for this reason
Owner Dale _
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury are of the following declarations
O 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
work for which this permit Ls taued.
C] 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' Compen 'ore Insurance carrier and PoltLnn7umher am:
Carter. Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit Is for mmc hundred do Bars (2100)
or less)
1 certify that in the perform&= of the work for which this permit is issued, 1 shall tot
employ any person in any manner so as to become subject to the Worbers' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become Subject to the Wortda Compensation provisions of No Labor Code. you must
Oforthwith comply with such provisions or thLs permit shall be deemed revoked.
Z 0" CONSTRUCTION LENDING AGENCY
1 hereby aM. des them is a corstsuetinn leading a (-+ t"t agency for cite performance of
C4 > the work for which this permit is issued (Six. 3097, Clv. C.)
aQ Lender's Name
Z Leaders Address
U 0 1 certify that 1 have mad tills application anal slate that the above information is
car s. correct. I agree to comply with all city and county ardinanco and sate laws relating to
0 building construction, and hereby wthorine representatives of this city to triter upon the
aabove -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
cA liabilitla,judgmonts, costa and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APP ICANT U ANDS ANDCOMPLY OMPLY WITH ALL NON -POINT
S G NS. i� .511001
Si a pplianUConsactor 1�o Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7 ✓
❑Yes �No
Will the applicant or jjj/yyyco�m building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Dis rin7
❑ Yes
1 have read the hazardous materials requirements wrier Chapter 6.95 of the Califor-
nia Health & SafelyCode, Sxdona 25505, 25533 and 25534.1 understand that if the building
does rot culcruly 4#57trnam, char it is may,responsibility to notify Le occupant of the
�j] whicfLjr . be met prior �Sst(2 of a,Ceryfir;3W of Omp'Ky _J , (%
408)536-0420
PERMIT ISSUE DATE
Job Description
CONTROL NO.
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
SHORE UP DECKS & STAIRS #301 & 306
Sq. Ft. Floor Area
31606037.BLDG9
Issued by:
Re -roofs
Type of Roof
Required Inspections
4- �XvAlri
on
Occupancy
Date J-1
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
or authorized agcnL V Date
All roof coverings to be Class's" or better