09030135BUILDING DIVISION PERNUT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHITEC UENGINEER:
c zo LICENSED CONTRACTOR'S DECLARATION
W pI hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
U., in full force and effect.
? License Class Lic• M
t.., O Date Contractor
gg ARCHrIECTS DECLARATION
cE I understand my plans shall be used as public records
yU
'
y 0 y Licensed Professional
1 OWNER -BUILDER DECLARATION
1
am I hereby affirm that 1 am exempt from the Contractor's License Law for the
:Q0 following reason. (Section 7031.5, Business and Professions Code: Any city or county
m 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
? t C that he is licensed pursuant to the provisions or the Contractor s License Law (Chapter 9
H (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 sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law dam 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
sal
I, as owner of the property, am exclusively contracting with licensed contractors to
tons ucl the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense
Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Seo. B & P C for this reason
Owner W
116101
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1-11 have and will maintain a Certificate of Consent to self -insure forWorkees Compen-
sation,
IhaveandwillmaintainaCertificateofConsenttoself-insureforWorkersCompen-
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 arc:
Cartier. Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($1011)
or Icss.)
I certify that in the performance of the work or whi m this permit is issued, I shall not
employ any person in any manner so as t c m su egl t2 fie Workers' Compensation
Laws of Califomia. ale VV --
Applicant
NOTICE TO APPLICA : If, after making is Certificate of Exemption, you s euiJ
become subject to the Workers Compensation provisions of the Labor Codc, you must
'7 forthwith comply with such provisions or this permit shall be deemed revoked.
4 O CONSTRUCTION LENDING AGENCY
..m ►�-m I hereby affirm that there is a construction lending agency for the performanm of
x r7 the work for which this permit is issued (Sec. 3097, Civ. C.)
4 A Lenders Name
Z Lenders Address
1 certify that I have read this application and state that the above information is
y Hcorrect. I agree to comply with all city and county ordinances and slate laws relating to
C> 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
�t rA liabilities, judgments, costs and expenses which may in any way accrue against said City
7 in consequence of the granting of this permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCEREG TIONS.
IS gnature of Applicant/Contractor Da
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici al Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
Cl Yes o
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 �jNo
1 have read the hazanlous materials requirements under Chapter 6.95 of the Cal 1for-
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, at it is my responsibility to notify the occupant of the
requirements which ytI be mel r to,7ce of a Certificate of Occuy�y.'
-fY1
Owner or authorized agent Da
PERMIT NO.
art uta c:1W4hrrr0
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
INSTALL WASHER/DRYER UNITS IN APTS—INCLUDES
E/M/P'S—SEE PERMIT #09030198 FOR PLAN CK
COMMENTS.
(DOUBLE FEES)
Ft. Floor Area I Valuation
APN Number Occupancy
32609.040.504
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
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'{." or better