09030172CITY,OF CUPER'TINU
BUILDING DIVISION PERIVIIT
BUILDING ADDRI
20875
OWNER'S NAME:
ARCHITECTIENGINEER:
IW
0 zo LICENSED CONTRACTOR'S DECLARATION
i cwt C I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z m with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
t Z License Class Lie. M
p Date Contractor
iq ARCHITECTS DECLARATION
i I understand my plans shall he used as public records
>yU
u. ti Licensed Professional
' OWNER -BUILDER DECLARATION
art
I hereby affirm that t am exempt from the Contractor's License Law for 0rc
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
? y y prior to its issuance, also requires the applicant for such permit to file a signed statement
a A that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
1, (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 ($500).
❑ 1, as owner of the property, or my employees with wages as their sale compensation,
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs 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-
b
uildill have the burden of proving that he did not build or improve for purpose of
wner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense taw 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 Contractors
License Law,
❑ I am xempt under Sea B & P C for this reason
Owner 1✓��/� ` Dale5u
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-insurc forWorkees 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 am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is foronc hundred dollars ($100)
or less.)
I certify that In the performance of the wet for ww+�ich this permit is issued, I shall not
employ any person in any manner soas�ebc agbjecl4 eWorkers'Compensation
Laws of California. Date 77 11 bb `` IIJJ
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.
OCONSTRUCTION LENDING AGENCY
tai I hereby affirm that there is a constructionlend ing agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
W A Lender's Name
,,z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
LIa H correct. I agree to comply with all city and county ordinances and state laws relating to
0 V building construction, and hereby authorim representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
E-4 P4
to liabilities, judgments, costs and expenses which may in any way accrue against said City
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL OMPLY WITH ALL NO -POINT
SOU CE REGUL TIONS.
Signat rc of pplicant/Contractor D_�—
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)?
Dyes 24.
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 u
PERMI I" NU.
118tr IM __ �.1
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
INSTALL WASHER/DRYER UNITS I = O !�
IN APTS—INCLUDES Job Description
Sq. Ft.
APN
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date ).Le,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.
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534, l understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant or the
requiremenhich usI be el p�or�f tss�co a—a certificate of Occup cy, Signature of Applicant Date
X�1 tet.. 5.12 16 � All roof coverings to be Class ".. 'or better
Owner or authorized aecnl Data