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CITY OF CUPERTINO
BUILDING DIVISION PERMIT�Ri�Z�MN;
p
BUILDING ADDRESS:
PERMIT NO.
OW KIP6 11RIAME:
PERMTT ISSUE DATE
,
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.
REV EXTERIOR ELVTN ALTERTNS FOR SIGNAGE (UNDR SEP
License ClassLic. 0
Date Contractor
PERMIT) ORG# 09010104
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alTirm that 1 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 rile a signed statement
Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
36906010 .10 0
0 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 Contractor's License Law duns 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 wipave the burden of proving that he did not build or improve for purpose of
sale.).
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 f0paLl,project with a contractor(s) 'tensed pursuant to the Contractor's
License Law.
01amexe B&P f this rg6op
LA
I hereby affirm under penalty of perjury one of the following declarations:
0 1 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.
0 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 are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for hi It this rmI, is uud hall of
employ any person in any mango ss o t o n
Laws of California. Date AJ
Applicant
'
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shoo
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 Uere is a construction lending agency for the performance of
i 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
COMM I 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
l
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which ay in any way accrue against said City
inconsequence of the granting this permi
�j t
APPLICANT UNDERSTA D ALL NON -POINT
Issued by: Date 2.2
SOURCE REGULATION
Q C/
Re -roofs
Type of F.00f
Signature of Applicant/Contractor Date
MATERIALS DISCLOSURE
HAZARDOUS
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal dc, Chapter 9.12, and the Health and Safety
Cale, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Cl Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants at defined by the Bay Area Air Quality Management
all new rr aterials for inspection.
District?
0 Yes t
1 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
doesnot cunendy have
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CITY OF CUPERTINO
BUILDING DIVISION P RAUT
BUILDING ADDRESS:
PERMIT NO.
OW NE1FOAME:
U U
PERMIT ISSUE DATE
4:24411 (29T EM2
A o. CONTROL NO.
(408)986-8711
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9 (commencing
Job Description
I hereby affirm that Iam licensed under provisions of
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
REV EXTERIOR ELVTN ALTERTNS FOR SIGNAGE, (=R SEP
License Class Lic. p
Date Contractor
PERMIT) ORG# 09010104
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (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) ur
0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
1) y yp
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars (S500).
36906010 0
❑ 1. as owner of the property. or my employers with wages as their sale compensation.
.10
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions code: The conuactoes License Law dors 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 wiPave the burden of proving that he did not build or improve for purpose of
of the property, am exclusively contracting with licensed contractors to
k�rctjcct
(Sec. 7044, Business and Professions Code:) The Contractor's U.
cense Law docs not apply to an owner of property who builds or improves thereon, and.
who contracts to projec with a contrector(s) 'tensed pursuant to the Contractor's
License Law.
❑ 1 am
DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 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 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 am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars ($100)
or less)
1 certify that in the performance of the work for whi h this ermil is' ucd all set
employ any person in any manper as bl2o t a ns a on
Laws of California. Date (�
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you shou
become subject to the Worker's Compensation provisions of the tabor Code, you must
forthwith comply with such provisions or this pennit shall be decreed revoked.
CONYMUCIION LENDING AGENCY
1 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)
Lenders Name
.
Lenders Address
I certify that 1 have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby aulhorire 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 ay in any way accrue against said City
in consequence of the granting
ALL NON -POINT
Issued by: Date
SOURCE REGULATION
/ L
Re -roofs
Type of Roof
Signature of Applicam'Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal de, Chapter 9.12, and the Health and Safety
Code, section 25532(a)?
❑ Yes o
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
'all new materials for inspection.
District?
_
❑Yes [�16
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505.25533 and 25534.1 understand that if the building
docs not currently have
Date . I
. All roof coverings to be Class 'J °' or better