09060080 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C(1I�AGTCT I�tMATIf�I :
BUILDING ADDRESS: PERMIT NO.
20853 SOLA ST FAST W1,TER HE
OWNER'S NAME: PERMIT ISSUE DATE
,) A CONTROL NO.
800) 4:54-8955
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
�y in full force and effect REMV/Rl'LC GAS WATER HEATER
? License Class Lic.x
C—a Date Contractor
ARCHITECTS DECLARATION
'a I understand my plans shall be used as public records
U
a
OG Licensed Professional
n rn.1 OWN DECLARATION
.1 I hereby atTirm that I am exempt from the Contractor's License Law for the
i a O following reason.(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 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 License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yF (commencing with Section 7000)of Division 3 of rhe Business and Professions Code)or 47
y 9 that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation. 35913008 . 0 0
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required ired Ins ections
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 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 themon,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 reason
Owner Dae
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self-insum for Worker's Compen-
,etion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 am:
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 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'Compensaton
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
Qforthwith comply with such provisions or this permit shall be deemed revoked.
Z"" CONSTRUCTION LENDING AGENCY
(~i I hereby affirm that there is a construction lending agency for the performance of
IYi 5 the work for which this permit is issued(Sec.3097,Civ.C.)
WCI.A Lendces Name
Z Lender's Address
U 0 I certify that I have read this application and state that the above information is
(y correct.I agree to comply with all city and county ordinances and state 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
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rA liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
r t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
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 Q No
Will the applicant or future building occupant aces equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air contaminants as defined by the Bay Area Air Quality Management all new r iaterials for inspection.
,strict?
❑Yes ❑No
1 have read the hazardous materials requirements under Chapter 6.95 or the Califor-
nia Hcalth&Safcty Codc,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 must be met prior to issuance ora Ccrtificae of occupancy. Signature:of Applicant Date
Owner or authorized agent Da1C All roof coverings to be Class'A"or better