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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
TRTYA
PERMIT NO.
NER'S NAME:
PERMIT ISSUE DATE
PHO
A O. a 9 CONTROL NO.
ARCHITECTIENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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 effect.
ADD MSIR SUITE, INCLD BTHRM&WLK—IN CLST;,ADD
License Class Lic. g
Date Contractor
LVRM&M'.TRA BDRM (7 2 6 SQ) &CHNG BDRM
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
INT0CL0ST/STRGRM&RE—STC0 ENTIRE HSE (1020SQ) ; NOT
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from rho Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, liter, 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 LiLcnse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7001) of Division 3 of the Business and Professions Code) or
540000
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
37523020 .00
❑ 1, 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 Tacwm Law docs 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors U -
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conrractor(s) licensed pursuant to the Contractors
License Law.
❑ lam exempt under�f,,e. B & P C for this mas_o�n,
:r Date�� r Z�!
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cerificate of Consent to self -insure for Workers Compen-
sation, 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 Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bo 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 manrtgr� aGc bject to the Workers' Compensation
Laws of California. Da F,,
Applicant s -
NOTICE TO APPLICA : 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 construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
L.endces Name
Landers Address
1 I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws misting to
building construction, and hereby authorise representatives of this city to enter upon the
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 any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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Issued b) : Date C
SOURCE GULATION
6 26 � `�
Re -roofs
Type of Roof
Signature of Applicant/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE
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
Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑ No
a roof s installed without first obtaining an inspection, I agree to remove
ll the applicant or future building occupant use equipment or devices which
Will
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Sections 75505.25533 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
re ui which m met priorto issuancof a Cerffcato of0c Pan
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Signature of Applicant ate
'nus
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All roof coverings to be Class 'A.' or better
Owner or authorized agent Datc