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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
CON CONSTRUCTION
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
SHO
A A O. CONTROL NO.
(408)942-8200
ARCHI7ECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
fob Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effectCOM'
L 'I I GRND FLR EXCVTN & RELOCTN OF UNDRSLB
License Class Lic. N
Date g 71, Y,
SVCS, CONS OF DPRSSD SLB AREAS FOR FUTURE TI
A CHITECrS DECLA N
I understand my plans shall be used as public records
INSTLTT OF EQUI PMNT ; NO EXTERIOR WORK (7 2 2 8 SQ )
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
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
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 Llccnse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$560000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
31622017 FLR 1
❑ I. as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work• and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contmtoes 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. Ute owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
[11. as 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.
❑ I am exempt under Sec B & P C for this reason
OwnerDate
WORKER'S COMPENSATION 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 Workces 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier. wsr➢olicy Na.: ` `�
CERTIFICATE OF EXEMPTION FROM WO CRS' ,
COMPENSATION INSURANCE
(This section need not be completed if the permit is for ono hundred dollars ($100)
or Icss)
1 certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Law s of California. Date
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
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.)
Lender's Name
L.endees Address
I certify that I have road this application and state that the above information is
cortecL I 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 c granting of this permit
APPLICANT DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU I ATIO S.
4601C
Re -roofs
Si u to r Jr
ppin HAZARDOUS ALS DISCLOSURE aar re
Type of Roof
Wi applicant or future building occupant store or handle hazardous material
as defy by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Co , ction 25532(a)?
Yes No
All roofs shall be inspected prior to any roofing material being installed.
❑ 8
If a roof i; installed without first obtaining an inspection, I agree to remove
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
all new materials for inspection.
District?
❑ Yeses
1 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 cu nd have a tenant that it is my responsibility to notify the occupant of the
require h must be met prior to issuance of a Certificate of Ocyppancy.
Signature of Applicant Date
All roof coverings to be Class'n" or better
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