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09040080serZ 200 �mZ U v? � 7yy 0 � 414pC uZ Y�eC L^ CITY OF CUPERTINO �-a�sLY111,����� PERMIT KA u� s f s ys BUILDING DIVISION BUILDING ADDRESS: PERMIT NO. 21071 GRENOLA DR TBD — TO BE DETERMINED 46 CONTROL NO. ARCHrmcr/ENGiNEER: BUILDING PERMIT INFO -BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that I an licensed under provisions of Chapter 9 (commencing with Section 700M of Division 3 of the Business and Professions Code, and my license is in full force andeffecL DD—MSTRBDRM, BATH, FAMILYRM, NOOK, KTCHEN (1344) REMODE Date, Contractor CCoontractor D—MSTRBDRM, BATH, FAMILYRM, NOOK, KTCHEN (1344) REMODEL ARCHITECPS DECLARATION 1 understandmyplans duillbcused aspublic records DINNING RM, LAUNDRY RM&PART OF KITCHEN (639) ; HV Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractor's License law for We following reason. (Section 70313, Business and Professions Code: Any city or county which requires a permit to construct. alter. improve, demolish, or repair any s ructum 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 Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 11 5 0 0 0 that he is exempt therefrom and the basis for the alleged exmmpthon. 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 (S_M 3228006.00 ❑ 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. 70". Business and Professions Code: The Contractor's License Law does not apply to an owner of property who budds or improves thereon. and who does such work himself or through his awn employes. provided that such improvements are not intended or offered for sale. If. - however, the building or impmvement 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 ). ❑ L as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec 7044. Business and Professions Coda:) The Conaactoes 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 COrthis n Owner"� Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following decluuions: ❑ I ham and will maintain a Certificate of Consent to self-insom for Workers Compen- sation, as provided for by Section 3700 of the Labor Code, far the performance of the work for which ads permit is issued. ❑ I have and will maintain Workers Compensation Ina'ancr, as mqudred 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 are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (This sectica need Trot be completed if the permit is far one hundred dollars ($ I00) or less) 1 certify that In We 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 Laws of California. Dale Applicant C�j -- _ NOTICE TO APP MATE11. after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. I - CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the perfm mamcc of ' the work for which this permit is issued (Sec 3097, CTv. C) - Lenders me Na Lenders Address j I certify that I have read this application and stare that the above Information is ' correct. I agree to comply with all city and county ordinances and slate lam relating to budding construction, and hereby authorize represcauv Ives 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 agahst j liabilities, judgments, costs and expenses which may In my way accrue against said City iin consequence of the granting of this permlL APPLICANT UNDERSTANDS AND WILL COMPLY NO POINT /+ Issued by: Date —2 (I SOUR . v L� M Re -roofs Type of Roof Signature IiuoNCom.ractor Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future budding occupant store or handle hazardous material ' as defined by the Cupertino Municipal Code. Chapter 9.17, and the Health and Safety Code, Section 75532(a)? All roofs shall be inspected prior to any roofing material being installed. C] Yes ❑ No If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which emit hwmdous air contarninsms as defined by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Ye. ❑ No I have read the hazardous materials requirements under Chaper 6.95 of the Califor- nia Health & Safety Code. Sections 25-5405.25533 and Z5534. I understand that ifthc balding does not currently have a tenant. that it is my responsibility to notify mccupan of the require must rr,>et�prior j� nssmarKm ora crnirrate mfq�ynL�. t ��f �U ly`1 Signature of Applicant Date y 1 All roof coverings to be Class '14" or better NDa1C Owner or authorized agent .