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CITY OF CUPERTINO
DIVISION PERMIT
BUILDING
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
PFiO rA
CONTROL NO.
ARCHITECT/ENGINEER'.
BUILDING PF.RMrr INFO
BLDG ELECT PLUMB MECH
0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that I am licensed under previsions of Chapter 9 (commencing
with Section 7008) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
RMDL $ATHRM r MINOR STRUCTUR (107 SQ )
License Class Lic.ff
Date Contractor
TaiN ECTSDECLARATION
I understand my plans shall be used as public records
i
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
i following mason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct. aper, improve. demolish, or repair any Structure
' prior to its issuance, also requires the applicant for such permitto file a signed statement
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
t that he is licensed pursuant to the provisions of the
(commencing with Section 70D0) 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
_S10000
APN Number
OCCUPanCY Type
Section 7031.5 by any applicant for a permit subjects dee applicant to a civil penalty of
not more than five hundred dollars (S50.
. 35621051 0 0
0 1, as owner of the property. or my employees with wages as their sok compensation.
Required Inspections
q
will do the wart and the structure Is not intended oroffered foraak(Sec.7044,Business
and Professions Code: The Contractus License Law docs nut apply to an owner of
property who builds or improves thereon, and who doessue:hwtrrk himself or through his
own employees, provided that such improvementsare not intended oroffered forsale. 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.).
Q 1, as owner of the property. am esduaively contracting with licensed contractors to
co"nucct the project (See. 7044. Business sad Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themor. and ,
who contracts for such projects with a cortuactor(s) licensed pursuant to the Contractor's
License LAW.
[jI am exempt under See. B k P C for this reason
'woer Date
s " WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to 'self-insum far Warkcr's Cumpco-
sadon, 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 require! 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 am:
Cartier. Policy No..
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic hundred dollars ($100)
or less.)
I eerily that k the performance of the W which this permit is issued. I shall not
employ any- person in anymamc _sub�ttnt"°VfitrYers'Cam nsatbth
b
� f„�-i�
Laws 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 Libor Code, you must
to forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Utas there is a construction pending agency for the performance of
> the word for which this permit is issued (Seo. 3097 Civ. C.)
Lund rs Name
Lenders Address
D I certify that I have read this application and state dim the above information is
y core--- i agree to comply with all city and county ordinances and state laws misting to
J building construction, and hereby authorise 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
(.Oa
Z in consequence of the granting of this permit.
-r APPLICANT UNDE ANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by Date
SOURCEREG'20NONS.
Re-roofs
T of F.00f
Type
Signature of Appiicant/Contaclor Date
HAZARDOUS MATERIAL, S DISCLOSURE
WLB the applicant or future Wilding occupant store or handle hazardous material
as ticfired by the Cupertino Municipal Code. Chapter 9.12• and the Health and Safety
-ode, Section 25532(a)?
All shall be inspected prior to any roofing material being installed.
Q Yes
roofs
a roof s installed without first obtaining an inspection, I agree to remove
ll the applicant or future building occupant use equipment or devices which
Will
emit hasardous air contaminants as defined by the Bay Area Air Quality Management
all new n laterials for inspection.
District?
❑Yes 'Vo
I have mad the hassrdous materials requirementsundcrChapter 6.95 of the Califor-
nia Hca]ih &SafctyCodo. Seedons255W, 25533 and25534. I understand thatif the building
does tot curtendy have a ant, that it is my responsibility to notify the occupant of the
mquimmcntswhic be met priortoissuanceOraCertifiateofDecnpan-)t
Signature of Applicant Date
"""�✓� '' ° y'`
All roof coverings to be Class '¢" or better
or auft&..ed agent Date