09030216BUILDING DIVISION PERNUT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHrrECT/ENGINEER:
O Zp LICENSED CONTRACTOR'S DECLARATION
es 1 hereby affirm at I am licensed under provisions of Chapter 9 (commencing
Z U that
with Section 7000) of Division 3 of the Business and Profcsions Code, and my license is
= y in full force and effect 1 Q
License C) I;,- t /
3 f o Date CD
ARCHrfECI,n TION�
oZ 1 understand my plans shall be used as public recnrda
a
g W. Licensed Professional
0 OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
%O O following mason. (Section 7031.5, Buslnass and Professions Code: Any city or county
K $ V which requires a permit to construct, alter. improve, demolish, or repair any structure
y z y prior to its Issuance, also requires the applicant for such permit to file a signed statement
7C < that he is licensed pursuant to die provisions of de Contractors License Law (Chapter 9
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
is $ that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 try any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S300).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will do the wort, and the structure is not intended or offered far sale (Sec. 7D44, Business
and Professions Code: 7ite Can't= f's I k=$c Law does not apply o an owner of
property who builds or improves thereon. and who does such wort himself or through his
own employees, provided that such impmvemets are not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.j.
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Ll-
causse Law does oot apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
L.L a Law.
❑ I am exempt under Sec. . B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Coda for the performance of the work for which this permit is issued.
My WorkQ�,s4Coom�pe�pstion carrier and Policy numb am:
Carrier iVY �'` Policy No,: (%
CERTIFICATE OF EXEMPTION FROM WO CEILT
COMPENSATION INSURANCE
(This section nerd not be completed if the permit is for one hundred dollars ($I013)
or Icsa)
1 cenify that in the performance of the work for which this permit is Ltmed, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Ccrtifiraic of Exemption, you should
become subjcc-e to the Workds Compensadon provisions of Lite Labor Coda you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
7O CONSTRUCTION LENDING AGENCY
[.-h 1 berth, affirm that there is a construction lending agency for the performance of
Ix the work for which this permit is issued (Sec. 3097, Civ. C-)
WfS. Q Lenders Name
a Z Lenders Address
U Q 1 certify that I have read this application and state that the above information is
"' correct I agree tocomply with all city and county ordinances and state lam relating toU building cortsenetion, and hereby authorize mpresentuives of this city to enter upon the
W above -mentioned propeny for inspection purpaus
GL (We) agree to save, indemnify Lad keep harmless the City of Cupertino against
h� Co2 liabilities, judgments. costs and expenses which may in any way accrue against said City
V 7 in consequence of the granting of this permit.
r� APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL No,
O POINT
S S. as S
1210
n of Applicant/Contractor V crate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oampant sore or handle: hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and de Health and Safety
Code. Section 25532(a)? ❑ Yes t`—P*
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Maoagcment
DisWn7
❑ Yes
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code. Section 25505, 25533 and 25534- I understand that if the building
does not currently have a� that It Ise my responsibility to notify the occupant of the
requir-prngwhir 12; Ws L prior to istranee,„ ga Certificate of Oceupapry. 1!7/_'r
a]a]M
PERMIT NO.
PBRMTr ESUE DATE
CONTROL NO.
BUILDING PeRmrriNFO
BLDG
ELECT
PLUMB
Job Description
SHORE UP DECKS#205,#208,#209Ķ&STAIRS #212,207
Sq.
Valuation
APN Number Occupancy Type
31606037.BLDG6
Required Inspections
t
Re -roofs
Type of Roof
Date _S7 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
. All roof coverings to be Class's" or better
0wna WiMhn>wj5d agent w Date '