09030205 CITY OF CUPERTINO r
BUILDING DIVISION PERMIT � `s' � sk�
BUILDING ADDRESS: PERMIT NO.
21979 SAN FERNAmno ANIF, ROB R
OWNER'S NAME: PERMIT ISSUE DATE
HO A O. CONTROL NO.
LST D71R
408) 279-2277
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION O O
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z 9 with Section 7000)of Division 3 of the Business and Professions Code.and my license is
'may in full force and effect RE-PLASTER PUBLIC POOL-BLACKBERRY FARM. CITY
DtR4 License Class Lic.8
Date Contractor JOB-NO FEES.
J9qARCHITECTS DECLARATION
U
a, I understand my plans shall he used as public records
ZC H Licensed Professional
0OWNER-BUILDER DECLARATION
MI hereby affirm that I am exempt from the Contractor's License Law for the
%G O following mason.(Section 7031.5,Business and Professions Code:Any city or county
.c$Pi which requires a permit to construct,alter,improve,demolish,or repair any structure
y Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
_`e that he is licensed pursuant to the provisions of the Contractor's Liu:cnse Law(Chapter 9 Sq.Ft.Floor Area Valuation
X F (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 araC APN Number Occupancy
not more than five hundred dollars(5500). P y Type
❑1,as owner of the property,or my employees with wages as their sole compensation, 35710005 . 00
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
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
71.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 contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am ex pt under Sec. B&P C for this mason
Owner Date (OO oq
ECLARATION
I hereby affirm under penalty of perjury 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
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as inquired 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 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 cenifv 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 be ome subject to the Workers'Compensation
Laws of Califl
Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
2 CONSTRUCTION LENDING AGENCY
[�►�- I hereby affirm that there is a construction lending agency for the performance of
�r the work for which this permit is issued(Sec.3097,Civ.C.)
WCC.A Lendees Name
Z Lender's Address
U Q I certify that 1 have read this application and state that the above information is
V. correct.I agree to comply with all city and county ordinances and state laws relating to
O V building construction,and hereby authorize representatives of this city to enter upon the
IJl above-mentioned property for inspection purposes
HOr (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way scene against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
5�-
Date
HAZARDOUS RIALS DISCLOSURE Type of Rcof
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)?
❑Yes [7�No All roofs sl Tall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new ma serials for inspection.
District?
❑Yes 0<0
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently have a tenant•that it is my responsibility to notify the occupant of the
requirements which most
eI prior to issuance of a Certificate of occupancy. Signature o F Applicant Date
_ (go-M All roof coverings to be Class n "or better
Owner or authorized agent Date g rT