09060120 CITY OF CUPERTINO
BUILDING DIVISION PERMIT INE
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
A A O. 9 9 9 CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
v p p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
Z with Scction 7000)of Division 3 of the Business and Professions Code,and my license is
1=y in full force anJjftecL ,,''',/'I 67h�Sa RE-RF T/0 WDSHKS INSTL. OSB SHEATHNG INSTL GAF-ELK
j ? License Class y)✓ rrr52L Con N
±Flo Dato•��rit
Z2 00'R / Contractor f �'� It. ASPHLT 3HNGLS 30LBS FLT CLS A 28SQ — BAUTISTA
ARCHITECTS DECLA tAT10N
I�U I understand my plans shall be used as public records BUILDER PD FOR BUS LICENSE
a
L y Licensed Professional
n y OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
1:00 following mason.(Section 7031.5,Business and Professions Code:Any city ar county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Zy prior to its issuance,also requires the applicant for such permit to file a signed statement
G that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $12698
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of
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(55001
❑1,as owner of the property,or my employees with wages as their sole compensation, 35617025 . 00
will do the work and the structure is not intended or offered for sale(Sec.70",Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q P
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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors o
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 exempt under Sec. B&P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
I 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 Compcn-
.hon,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 required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation insurance carrier and Policy number am: ..fi�tt
Carrie -57-AF,1 A' Policy No
��V�,
CERTIFICATE OF EXEMP11ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or Ices)
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z. CONSTRUCTION LENDING AGENCY
[~+CA I hereby affirm that there is a construction lending agency for the performance of
a 5 the work for which this permit is issued(Sec.3097,Civ.C.)
t>:)W Q Lendces Name
Z Lender's Address
U 0 I certify that I have read this application and state that the above information is
V. correct.l agree to comply with all city and county ordinances and state laws mladng to
0V building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mendoncd property for inspection purposes
(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
V Z in consequence of the granting of this permit �
►'I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by Date > 2-L
,o-�
" f Re-roofs
Signature of Applicant/Contractor Dale T Of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 ;hall be inspected prior to any roofing material being installed.
❑Yes Q7Go
Will a roof i;installed without first obtaining an inspection,I agree to remove
ll the applicant or future building occupant use equipment or devices which
't hazardous air contaminants is defined by the Bay Area Air Quality Management all new materials for inspection.
Act?
❑Yes
I have read the hazardous materials mquiremcns 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 w ch must be f a Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class') "or better
Owner or authorized agent Date