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CITY OF CUPERTINO
DIVISION PERMIT
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BUILDING
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BUILDING ADDRESS:
PERMIT NO.
)T,F ROOFING
')WNER'S NAME:
PERMIT ISSUE DATE
PHO
SA CONTROL NO.
ARCHrfECT/ENGINEER:
BUILDING PERMIT INFO
RE -ROOF REMOVE EXISTING
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
WOODSH��KE, INSTALL OSbb Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and e
License Class Lle. 0_
Date Contractor
CHITECPS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
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 License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) 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
APN Number
Occupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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. 7044, Business
and Professions Code: The contractors 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 be 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 Contractor's 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 contractor's
License Law.
❑ I am exempt under Sec. B & P C for this reason
'wner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
which this permit is issued.
7work
I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
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Cartier. 7 lit [rJ" � Policy No.: CM244 —Xv
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 certify that in the performance of the work for which this permit is issued, 1 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 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 consuuction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
j I certify that I have read this application and state that the above information is
correct. l agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
1
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 an way accrue against said Cit
1 j g fk Y Y Y g Y
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
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Re -roofs
'I of R)of
ype
Signature fApplicant/Contractor °ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municip Codc. Chapter 9.12, and the Health and Safety
,,ac, Section 25532(a)?
All roofs :,hall be inspected prior to any roofing material being installed.
[:3 Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Iding occupant use equipment or devices which
emit hazardous air contaminants Jefhncd by the Bay Area Air Quality Management
all new m lterials for inspection.
District?
❑ Yes ❑ No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHealth & Safety Code, Sections 255U5,25533 and 25534.1 understand that if thc building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requir s hich must be met prior to issuance of a certificate of Occupancy.
Signature A Applicant Date
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roof coverings to be Class' n" or better
Owner or authorized agent DateAll