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CITY OF CUPERTINO
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BUILDING DIVISION PERNUT
BUILDING ADDRESS:
PERMIT NO.
21617 ROSARIO AVE
F W RAYE CO INC
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OWNER'S NAME:
PERMIT MUE DATE
)S
CONTROL NO.
ARCHIiECT/ENGiNEER:
BUILDING PERMIT INFO
FIRE REPAIR TO KITCHEN TO
BLDG ELECT PLUMB MECH
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LICENSED CON7RACIO"DECLARATION
INCLUDE CABINETS, Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(IO) of Division 3 of the Business and Professions Code, and my license is
^"— ^ ^ ^ ^ ^
in full force and effect Lle. N
.
License Class
Date _—.T=� Conuacfnr e
ARCHrrECrS DECLARATION,
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conuaetoes License Law for the
following mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to conauuct. alter, 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 7000) of Division 3 of the Business and Profasiona Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any vio,if. of
APN Number
Occupancy T
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Section 7031-5 by any applicant for a permit subjects the applicant to a civil penalty of
no t more than five hundred dollars ($500).
❑ C as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the worn, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Coder 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 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 rat build err improve for purpose of
sale.).
❑ 1. as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Prof isiors Code:) The Coatraaor's U-
curse Law does not 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 Commuor's
License Law.
❑ I am exempt under Sec , B & P C far this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to selFinsum for WorkcesCompen-
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 Worlds Compenutlon 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 Compensation Insuni nce carrier and Policy number am:
Came- -57i1 "re, Policy No.: /_fS 6 ClL4 2C0
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
.
filth section need sal be completed if the permit is for one hundred dollars ($100)
or lest)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mauncr so as to become subject to the Worldd Compensation
Laws of California. Dale
Applicant
NOTICE To APPLICANT: If, after 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 or this permit shall be deemed mvokcd
CONSTRUCTION LENDING 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.)
Lender's Name
'
Lender's Address
I certify that I have read this application and state that the above information is
'
correct- 1 agree to comply with all city and county ordinances and state laws relating to
b"ding consuuction, and hereby authorize repmsensUves of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, toss and expenses which may In eery way accrue against said City
In consequence of the granting Of this pCririL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE EGU TIONS.
Re -roofs
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HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazArdous material
as defined by the Cupertino Municipal Codc- Chapter 9.12. and the Health and Safety
Code. Section 25532(a)T
❑Yes m,Na
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as dcfnncd by the Bay Area Air Quality Management
all new materials for inspection.
Disuict7
❑ YesPdu
1 haver mad the hazardous materials requimmens under Chapter &95 of the Cailfor-
cia Health & Safety Code, Sections 25505.25533 and 25334.1 understand thatif der building
does not currently have a tenant, that It is my responsibility to notify the occupant of the
requirements must be met pnor of Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class'%" or better
Own or wthorvrd agent Dam