09040081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT � '
PERMIT NO.
BUILDING ADDRESS:
19110 TIL
'NER'S NAME: —
PERMIT ISSUE DATE
A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECI7ENGINEER:
BLDG ELECT PLUMB MECH
u p zo LICENSED CONTRACTOR'S DECLARATION Job Description
m C I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z rat with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'may in full force and effect. REVISIOrf—DECREASE LARGE SIZE FROM 744 ' TO
-z License Class Co 8 6 2 4 ' .MOVE DOOR TO RIGHT SIDE OF GARG,ADD WINDOW.
Lu Date ARCHITECTS DECLARATION
� U
I understand my plans shall be used as public records INCREASE DISTANCE BETWEEN GARAGE & 2ND UNIT. 2ND
Oy Licensed Professional
y� OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
in O following reason.(Section 7031.5,Business and Professions Code:Any city or county
4$V which requires a permit to construct.alter,improve,demolish,or repair any Wwtum
as"In prior to its issuance.also requires the applicant for such permit to rile a signed statement Valuation
_z>- .Ft.Floor Area
� that he is licensed pursuant to llue provisions of the Contractor's License Law(Chapter 9 �q
Y f- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
so
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
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($5M 3750900'- . 19110
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(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 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
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense 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 Contractor's
License Law.
❑I am e t undo Sec. ,B&P C far th' reason
KER'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 self-insure for Workees 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 Compensation Insurance carrier and Policy number are:
Carrier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is for one hundred dollars(5100)
or less)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the W rl(rs'Compensation
Laws of Cali�whr�r Date
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
,Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
►rA.c I hereby affirm that there is a construction lending agency for the performance of
p(> the work for which this permit is issued(Sec.3097,Civ.C.)
0 Lender's Name
Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LU" corccL I agree to comply with all city and county oniinances and state laws relating to
0 U building convection,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
a (Wc)agree to save,indemnify and keep harmless the City of Cupertino against
„F,c In liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date
0-4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PO Issued by:
SOU ATION . ' 6
Re-roofs
actor
Signature o Applicant/ContrD
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
is defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
dc,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
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 defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑Nu
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant.that it is my responsibility to notify the occupant of the
rcyui u which must be met prior uapce o a Certificate of Oc Signature of Applicant Date
All roof coverings to be Class". or better
Owner or authorized agent D re