09060135 P 77
CITY OF CUPERTINO
BUILDING DIVISION PERMIT �� "'' '
PERMIT NO.
BUILDING ADDRESS:
21639 ED
PERMIT ISSUE DATE
(408) .496-996C)
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
u O p LICENSED CONTRACTOR'S DECLARATION Job DCSCnptlOn
V 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
� y REPLACE 11 WINDOWS 2 . PATIO DOORS LIKE FOR LIKE
in full force and effect.
Z License Class Lie.M
Date Contractor
t ARCHITECTS DECLARATION
tt I undersand my plans shall be used as public records
7yU
y u.y Licensed Professional
rn OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
r a o following mason.(Section 7031.5,Business and Professions Code:Any city or county
K which requires a permit to construct,alter.improve,demolish,or repair any structure
prior to its issuance.also requires the applicant far such permit to file a signed saacmcnt Ft.Floor Area Valuation
z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 3q
yH (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
g R_ that he is exempt therefrom and the basis for the alleged exemption.Any violation o[ Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
not more than rive hundred dollars($500)• 35619012 . 00
❑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 Required Inspections
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-
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
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 themon,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
owner ' Date
— WCI KER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
-don,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 am:
Cartier. Policy No.:
CERTIFICATE OF EXEMP77ON FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars($100)
or less)
I certify that in the performance of the work for which this permit is issued.l shall not
employ any person in any manner so as to become subject to the Workers'Compensadon
Laws of California Daae
Applicant
NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
,ZCONSTRUCTION LENDING AGENCY
[~-t tom. I hereby affirm that there is a construction lending agency for the performance of
5 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
az Lenders Address
1 certify that I have read this application and sate that the above information is
correct.I agree to comply with all city and county ordinances and sate laws relating to
0 V building construction,and hemby authorim representatives of this city to enter upon the
W above-mentioned property for inspection Purposes
CL (We)agree to save,indemnify and keep harmless de City of Cupertino against
CA liabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consequence of the granting of this permit. Date
►4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by
SOUR
{�REG TIONS.
• 6 (,1-93 Re-roofs
Sig of Applicanl/Conlractor DateF T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cotte,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Cl Yes t$(NO
- If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment of devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
strict? ��tt""
C3yes epmu
1 have mad the hawdasrmatcrials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCode,Sections 25505.25533 and 25534.1 understand mat if thc building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements w het rept prior to issuance of a Ccnificale of Oqcupan Signature of Applicant Date
y G�a3 � All roof coverings to be Classn"or better
Owner or authorized agent Date