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41
CY OF CUPERTII
BUILDING DIVISION
)ING ADDRESS:
OWNER'S NAME:
ARCHITECT/ENGINEER:
PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Profcssioru Code. and my license is
in full force and effect.
License Class Lic• g
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alTirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. 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
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not mors than five hundred dollars (5500).
❑ L 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 We (Sec. 7044, Business
and Professions Code: The contractors 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 wjll have the burden of proving that he did not build or improve for purpose of
Vas 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.
❑ 1 —t under See. B& P C f this n
Owner lt` /`� tMMDare
WORKER'S COM SATION 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 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.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Chis section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the wqrk for ich this permit is issued. I shall not
employ any person in any manner c6nc b' Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. if, after making this Certificate of Exemption, yeu 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 revoked.
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.)
Lenders Namc
Lender's Address
I certify that I have read this application and state that the above information is
corrccL 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives 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, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT
SO E REGUL ONS.
Signature of Applicant/Commictor are
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)?
❑ Yes W+lo
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
District? l
❑Yes Leo
I have read 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 or the
requirements which must be met pr" to issu{nce of a Certificate of Occupangr
r A
Owner or a orzod agent - 'Date
PERMIT NO.
PERMIT ISSUE DATE
S R CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
INSTALL WASHER/DRYER UNITS IN APTS-INCLUDES
E/M/P'S-SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
. Ft. Floor Area
32609041.223
Issued by
Re -roofs
Type of Roof
ber
Required Inspections
Valuation
All roofs shall be inspected prior to any roofing material being installed.
If a roof i s installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
All roof coverings to be Class'n" or better
Date