09030180BUILDING DIVISION PERMIT
rING ADDRESS:
OWNER'S NAME:
ARCHMC-r[ENGINEER:
p p LICENSED CONTRACTOR'S DECLARATION
i U p l hereby affirm that I am licensed under provisions of Chapter 9 (commencing
; z w with Section 70100) of Division 3 of the Business and Professions Code, and my license is
o in full fares and effect.
i ,yz License Class Lic. A
E„ p Date Contractor
ARCHITECTS DECLARATION
i I understand my plans shall be used as public records
7aU
'
U. y Licensed Professional
y OWNER -BUILDER DECLARATION
j < I hereby affirm that 1 am exempt from the Contractors License Law for the
. a o following mason. (Section 7031.5, Business and Professions Code: Any city or county
<� which requires a permit to construct, alter, improve, demolish, or repair any structure
zy prior to its issuance, also requires the applicant for such permit to file a signed statement
e G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
a t- (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 any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 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
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
c nslruct the pmject (Sec. 7144, 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 comractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C or this reason
Owner 1 t l A we 01� Date 6 U c
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Warkces 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 Workers Compensation Insurance carrier and Policy number ate:
Carrier. Policy No.:
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of thev�ork fOor hi ch this permit is issued, I shall not
employ any person in any manner to becpme ubj'M tM6C Workers' Compensalfan
Laws of California. Dec _ U �(
Applicant ' VVI w
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shood
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.
O0 CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
x r7 the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lenders Name
0z Lenders Address
J 0 1 certify that I have read this application and state that the above information is
Hcorrect. I agree to comply with all city and county ordinances and state laws relating to
U building construction, and hereby authorize representatives of diis city to enter upon the
Uabove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
fn liabilities, judgments, costs and expenses which may in any way accrue against said City
`L in consequence or the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- OINT
SO RCEREGULATjONS.
Signature of Appiicant/Contraclor Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum 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 a
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?
❑Yes o
have read the hazardous materials requirements under Chapter 6,95 of the Califor-
nia Health & Safety Code, Sections 25505.2 5533 and 25534.1 understand That if the building
does not currently have a tenant, that it is my responsibility to notify the Me ant of the
req ' cots which must m prior to' ifFe of ate of Cap. yy� /
Owner or or authorized agent��/agent/
PERM[I- NO.
n9nnl Rn
PERMIT ISSUE DATE
SAN CONTROL N0.
BUILDING PERMIT INFO
INSTALL WASHER/DRYER UNITS I eO
IN- APTS—INCLUDESTT Job Description
Sq. Ft. Floor Area
APN
Required Inspections
Issued by:
Re -roofs
Type of Roof
on
Occupancy
Date 5, LO,O
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 'A" or better