09060111 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �1 '�:ATC?R
BUILDING ADDRESS: PERMIT NO.
PERMIT ISSUE DATE
"!O099
A A O. CONTROL NO.
ARCHfIECT/ENGINBER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION
UI hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
W with Section 7000)of Division 3 of the Business and Professions Code,and my license is
o y in full force and effect DEMO P1=0
Z License Class Lie.#
&—a
Date Contractor
ARCHITECTS DECLARATION
o.
U I understand my plans shall be used as public records
O In Licensed Professional
�-I OWNER-BUILDER DECLARATION
2 1 hereby affirm that I am exempt from the Contractors License Law for the
COO following reason.(Section 7031.5,Business and Professions Code:Any city or county
� which requires a permit to consuact alter,improve,demolish,or repair any structure
y Z 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 Lice=Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of $100
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). P Y YP
❑I,as owner of the property,or my employees with wages as their sole compensation, 35705005 . 00
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or thmugb 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 Contractors Li-
cense law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑1 am exempt
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insure for Workers Compen-
.cion,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 required 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:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less)
I certifv that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner�p as to become subject to the WR!ers'Compensation
Laws of California.DateC
Applicant �—
NOTICE TO APPLICANT: Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
'Z t--t CONSTRUCTION LENDING AGENCY
..r
F-t I hereby affirm that there is a construction lending agency for the performance of
Ix the work for which this permit is issued(Sec.3097,Civ.C.)
�W Q Lenders Name
Z Lenders Address
V Q 1 certify that 1 have read this application and state that the above information is
ly correct I agree to comply with all city and county ordinances and stare laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes
fy (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City J
V Z in consequence of the granting of this permit / r
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
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
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes t�No
Will the applicant or future building occupant use equipment or devices which If a roof i3 installed without first obtaining an inspection,I agree to remove
E hazardous air contaminants as defined by the Bay Area Air Quality Management all new rr aterials for inspection.
trict?
❑Yes 94
I have read the hazardous materials mquiremcns under Chapter 6.95 ofthe Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
of Occupancy.
4;; �gf/0
Signature of Applicant Date
Owner or authorized agent Date All roof coverings to be Class"A"or better
OR O U t ( I
CITY OF CUPERTINO
" DDEMO
CUPEkT1NO PERMIT APPLICATION FORM
APN#
(� ' 00
00 ate:
Building Address:
2346/Vj� �/.e laK.
Mailing Address (if different from building add-ess):
Owner's Name: Phone:
#:
Cupertino Business License#:
Contact: Phone:
Fax:
Residential E?"`Sq Footage Commercial ❑ Sq Footage
Job Description:
Valuation:
No f Co n ilP,�.,4 1 C 0 1) f'
Project Size: Express Standard ❑ LE rge ❑ Major ❑
Please complete relevant portions of the Grein Building Checklist & attach it to the application
or if applicable, include on the plan set & the sheet index.
Quantity Fee ID Fee Description Fee Group Permit Type
1DEMORES Demo-Residential B 1SFDWL-DEM
1DEMOPRES Pool Deino Residential B 1SFP00L-DEM
1BCBSC Cal Bldg Standards B ALL PERMIT
Commis3ion Fee TYPES
/ 1BSEISMICRE Seismic Residential B
/ _ i S P R F I FE EF Revised 01/07/09