09060023 CITE OF CUPERTINO
BUILDILREGNART
PERMIT
PERMIT NO.
BUILDING AD
2232RD ATLAS—TROWNER'S NA
A CONTROL NO,
PHONE:
D (408) 28.6-8931 BUILDING PERMrr INFO
ARCHITECT/ENGINEER: BLDG ELECT' PLUMB MECH
a p C LICENSED CONTRACTOR'S DECLARATION Job Description
III(= I hereby affirm that I am licensed under provisions of Chapter 9(commencing
U U with Section 7000)of Division 3 of the Business and ProfessionsJpdc.and my license is R R P LC FURNACE
=y in fu11 force and effeaCt U Lie 6f`�,_C
j vn Z License Class CC... -
t-C Dam Conu -
III ARCHITECrS DECLARATION
D1 understand my plans shall be used as public records
U
tL , Licensed Professional
OWNER-BUILDER DECLARATION
n>.
< 1 hereby affirm that I am exempt from the Contncton s License Law for the
co 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
y^N prior to its issuance,also requires the applicant for such permit to file a signed statement 3 .Ft.Floor Area Valuation
Z< tial he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q
Yr (commencing with Section 7000)of Division 3 of ane Business and Professions Code)or 1 5 0 0
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ppN 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(s500). 36639001 - 00
0 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 We(Sec.7044,Business Required Inspections
and Professions Cade:The Contractor's License Law does 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.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The ContraetOes 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.
0 1 am exempt under Sec B&P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
�6.and will maintain a Certificate of Consent to self-insure for Worker's Compen-
on,as provided for by Section 3700 of Ute Labor Code,for the performance of the
#4 for which this permit is issued.
YM ,Uorkees
ve and will maintain Worker's Compensation Insurance,as tcquimd by Section
the Labor Cade,for the performance of the work for which this permit is issued.
C pens • n Insurance carr)cr and Policy number am: G
Carrier �� Iicy No.: U
CER FICATE OF EXEMPTION FRO WORKERS'
COMPENSATION INSURANCE
(Ibis 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.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
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 Labor Cade,you must
,J z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0 CONSTRUCTION LENDING AGENCY
E~.r rA I hereby affirm that there is a construction lending agency for the performance of
p; the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
aLender's Address
U 0 I certify that I have mad this application and state that the above information is
GL H correct.I agree to comply with all city and county ordinances and state laws mlating to
O U building construction, me
and hereby authorize representatives of this city to enter upon
above-mentioned property for inspection purposes.
(Wc)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments,costs and expenses which may in any way accrue against said City
V z in consegthence o ting of this permit. Date J'd
n--h APPLI ND TANDS AND WILL COMPLY WITH ALL NO -POINT Issued
SOUR />
2 Re-roofs
Cgnaiuim of Applicant/Contracto Dare 'I of:Zoof
HAZARDOUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munigipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof: shall be inspected prior to any roofing material being installed.
0 Yes No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or utum building occupant use equipment ordeviceswhich all new I naterials for inspection.
nit hazardaus air contaminants as defined by the Bay Area Air QualityManagement
strict? ( N
0 Yes
I have read the ha72rdaus materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
docs not current ve a tenant,th}}t it is my responsibility to notify the occupant of the ate
mquimmc�a c ust be m pfior to issuance o[a Certificate o cu cY• Signator Of App ' t
All r f coverings to be Class'A"or better
0 or authorized agent------ are