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BULDING DIVISION P�t, T
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021H
3tih . t..'
BUILDING ADDRESS.
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
CONTROL NO.
ARCHITEC (ENGINEER
BUIIZING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Pmfcssiem Code, and my license is
in full force and effect
LOWER DECK RMDL & LANDSCAPING
License Class LJc.
Date Contractor
ARCHITECTS DECLARATION
I understand my plans stall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 70315, Business and Professions Cade: Any city or county
which requires a permit to ennunict alter, improve, demolish6 or repair any structure
prior to its issuance, also requires the applicant for such permit to ride a signed stalcntent
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Profdssions Code) or
that be la exempt therefrom and the basis for the alicged exemption. Any violation of
APN Number
Occupancy
P y `'
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of
no mole than five hundred dollar (SM
32616089
❑ L as owner of the property. or my employers with wages as their sole compensation.
.00
Required Inspections
will do the work and the structure Is not intended or offered for sale (Sec 7044, Business
and Professions Cade: The Condracmr's License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employces, 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 Barued contractors to
construct the pro)= (Sec 7044. Business and Professions Coda) The Contractor's Li-
cmm Law does sot apply to an owner or property who builds or imposes thereon, and.
who contracm for such pojects with a eonawtor(s) rk wwd pursuant to the Contractor's
License Taw.
❑ 1 ern exempt until See.
hereby alum under penalty of perjury am of the following declarations
❑ 1 have and will maintain a Cenifcsu of Consent to self-itwm for Waftes Compen-
tation is provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation lusurancr, as required by Section
3700 of the Labor Code, for the performance of die work for which this permit is issued.
My Workees Compensation Insurance artier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nits scalon need not be compieted if the permit's fa one hundred dollars(S 100)
or less.)
I certify that in the performance of due work for which this permit is issued. I shall rot
employ airy pendm in any m rc>
, you amid
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be d=med revoked.
CONSTRUCTION !ENDING AGENCY
I hereby affirm dud dery Is a construction lending agency for the performance of
sine work for which this permit is issued (Sec. 3097, Clv. C.)
Lender's Nano
Lender's Address
I certify that l.have dead this application and }(ply that the above Information is
correct I agree tb.comply iv)th•all Oi;y tad ooanpr ordTeataees trod suite bt + relating to
building ceastrgctiep and2nereby aatlauine rt prdx(rtat m of this city to old upon tic
above-memi4cd1pmp2ryr0r•Trtgp Phan. Putp—s. .
(We)•agreeAceaave.indemnityig)tetip:-ftOwofCaperti!m wiw
Baconseq, jirwm gCth eeais amd.af Ods pa ! nley is !r!y rny.aceruc ajpJe;LsaiQ tY
Ins consegtclidx �:We,granting of tjns perptlt . • . .. . • .. .:
APPLICANft' ;UN=zTAHM A0 ?W.IY 1 ¢¢MPLY Wins Ails NOM-PD
SOURCE RE
• .... ' +
Issued by: Date C/J��
Re -roofs �—
silptature O-r�a9n&-igwfii
HAZARDOUS MATERIALS DISCLOSURE
. .
Type of Roof
Will the applicant or foturc building occupant store or handle haardous maserW
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
cam, seaian 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes � No
If a roof is installed without first obtaining an inspection, I agree to remove
VAII the applicant or future building occupant use equipment or devices which
emit hrurdous air cmutrainanu as defined by the Bay Area Air Quality Management
all new materials for inspection.
DW ictT
❑ Yes No
I have read doe sib rcquimmcros under Chapter 6.93 Of tic Califor-
nia Health sit SafetyCom S=kxts 2550.S.25S33 am12SS34. I utdcrstand thst If th building
does not currently have ajolm, that it is my respmnaibuity to notiry duo occupant of site
requirements which must ter to ram. ,, �, ova CrnifrsN sir
Signature of Applicant Date
" ;?" ' "`' -2 �
All roof coverings to be Class '%'' or better
Owner
or whorved agent Date