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CITY OF CUPERTUN
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMrr NO.
18760 TILSON AVE
TBD - T BE
OWNER'S NAME:
FERMrr ISSUE DATE
:
A 0 9 CONTROL NO.
ARCHrTEGT/ENGINEER.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby affirm that I am provision licensed wrier provisioof Chapter (commencing
with Section 7000) of Division 3 of the Business and Profcavoms C and my Hem= is
)
in full fineeand eff
Z
REVISE TRUSS CALCS(ORIG #08090114)MINOR INTERIOR
Date cotract"
REVISIONS.
ARCHrTECrS DECLARATION
I understand my plan shall be uicd as public nuaruh
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Coda Any city or county
which requires a permit to construct, after, 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 LIctmse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Suction 70011) of Division 3 of the Businessand Professions Code) or
that he is exempt thuefrone and the bads for the alleged exemption. Any violation of
APN Number
Occupancy
P y Type
Section 7031.5 by any applicant for a permit subjc = the applicant to a civil penalty of
not moo than five hundred dallars ($500).
37517040.00
❑ L as owner of the property. or my employees with wages as their sale compensation,
Required Inspections
win do the worn and the stnscrwe Is not Intended or offered for sale (Sec 7044, Business
and Professions Code The Contracwrs 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 cmpbyem irovided that such improvements are not intended or offered for sale 11,
however, the building or improvement Is sold within one year of completion, the owner-
.
builder will have the burden of prming that he did not build or improve for purpose of
scab.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The Coutractees U
cerse Law does not apply to an owner of property who builds or improves tbemoo, and,
who contracts for such projects with a contractors) hewed pursuant b the eontractara
I I=.— Law.
❑ I am exempt under Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-Inswm for Worker's Cornper
salon, as provided for by Section 3700 of the Labor Code. far the performarra of the
wart for which this permit Is Issued.
❑ 1 have and will maintain Worker's Compensation Iawrame, as requited by Section
3700 of the Labor Code, for the performance of the work for which this permit Is lamed.
carrier and
INSURANCE
(This section need rot be completed If the permit is for am hundred da"m (S 100)
or less.)
1 certify that In the performance of the wart for which this permit is issued, 1 shall not
employ any person In any manner sou to become subject to the Waskcrr Compensation
.
Laws of California. Dab
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor code, you must
forthwith comply with such provisions or this pmnit shall be demned revoked.
CONSTRUCTION LENDiNG AGENCY
I hereby &Mrm that there is at construction lending agency for the performance of
the wort for which this permit is issued (Sce. 3097. C.nv- C)
-
Lendee Namc
Lender, Address
1 certify that 1 have read this application and state that the above infomradon is
cortecL 1 agree to comply with all city and county ordinances and stab laws foisting to
building construction, and herby aulhorire representatives of this city to enter upon the
above-memioned property for inspection purposes
.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilitiMjudp9-,(-%cosulnAcxpensc which may in any way accrue agdnrisdd City
inc of
DISCLOSURE Dab
Will ke applicant or future building occupant stare or handle baardous maserial
u defined by 1hc Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Cade, seam, 25532(a)7
All roofs shall be inspected nor to an roofing being
❑Yes e�
material installed.
P P� Y 8 g
If a roof is installed without first obtaining an inspection, I agree to remove
WIH iho applicant or future building occupant use equipment or dcvias width
emit ha4ardous air contaminants as Wried by the Bay Area Air Quality Mansgement
all new materials for inspection.
District?
❑Yes ❑No
1 have read the hvandcs rnateials requirements under Chapter ti.95 of the CaHfor-
nla heal y
Applicant Date
J o
All roof coverings to be Class 'j�" or better
o Date'