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09050067 CITY OF CUPERTINO BUILDING DIVISION PERMIT BUILDING ADDRESS: PERMIT NO. rr OWNER'S NAME: PERMIT ISSUE DATE HONeOMET EUS REAh ESififtTE 1" YAMAY CONTROL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH o p LICENSED CONTRACTOR'S DECLARATION to1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description Z W with Seedon 7000)of Division 3 of the Business and Professions Code,and my license is y in full forceandeffect sQ R&R WHEELCHAIR LIFT LIKE FOR LIKE Z Licen CI Lic. F O Date Contractor ARCHITECCS DECLARATIO o. U 1 understand my plans shall be used as public records y Licensed Professional n OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for the is O O following reason.(Section 7031.5,Business and Professions Code:Any city or county K V which requires a permit to construct,alter,improve,demolish,or repair any structure Z y prior to its issuance,also requires the applicant for such permit to file a signed statement x`e that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation Y h (commencing with Section 7000)of Division 3 of the Business and Professions Code)or A that he is exempt therefrom and the basis for the alleged exemption.Any violation of S15000 Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than five hundred dollars(5500). ❑1,as owner of the property,or my employees with wages as their sole compensation, 369010:!6 . 03 will do the work,and the structute is not intended or offered for sale(Sec.7044,Business and Professions Code:The Contractors License Law does net 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 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 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 dt P C for this mason Owner Date 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- 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 required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensatio Insuranc artier and Policy number am: Carrier.S Policy No.:2 1. 1 ©2 'CERTIFICATE OF EXEMPnON 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'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Workces Compensation provisions of the Labor Code,you must Oforthwith comply with such provisions or this permit shall be deemed revoked. Z►-t CONSTRUCTION LENDING AGENCY I hereby affirm that them is a construction lending agency for the performance of i� the work for which this permit is issued(Sec.3097,Civ.C.) WR.A Lenders Name Z Lenders Address V 0 I certify that I 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 relating to 0U building construction,and hereby authorise representatives of this city m enter upon the Oa above-mentioned properly for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against lA liabilities,'ud mens,costs and expenses which may in any way accrue against said City IJ 2in co uenc the granting of this permit. ] ^ G APPLI A U AN WILL COMPLY WITH ALL NON-POINT Issued by: Date f� SOUR R LATIO Re-roofs Signatu of Applicant/Contramor Dale HAZARDOUS MATERIALS DISCLOSURE Type of Loof Will the applicant or future building occupant store or handle hamnlous material as defined by the Cupertino Municipa ode.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 logo 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 ss ncd by the Bay Area Air Quality Management all new materials for inspection. District? C]Yes o 1 have read the hamnio us materials requirements under Chapter 6.95 of the Califor- nia licpVM Safety Cade,Sections 25505.25533 and 25534.I understand that if the building does of cu ntiy ant,th is my responsibility to notify the occupant of the u" me luchml Iprio aeni cof�ca Signature of Applicant Date ownchpc,authori7.cdagccnl Date All roof coverings to be Class'J ''or better LU z� -may 3F'u�i jyU °a Yp0 ,'dmPi any _ZY FFO 0z z0 .r C/1 W> a az UO w F, OU �r V1 Uz CITY OF CUPERTINO BUILDING DIVISION PERNIIT�iR�tiZ Z�RT1�N. BUILDING ADDRESS: PERMIT NO. OWNER'S NAME: PERMIT ISSUE DATE PHO A CONTROL NO. ARCHrrECUENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION 9 Job Description I hereby affirm that 1 am licensed under provisions of Chapter (commencing with Section 701M) of Division 3 of the Business and Professions Code, and my license is in full force and effect ~�s'�' Sec R&R WHEELCHAIR LIFT LIKE FOR LIKE Licen CI s Lie. Date Contractor ARCHITECTS DECLARATIO 1 understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the fallowing 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 suchpermit 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) or that he is exempt therefrom and the basis for the alleged exemption. Any violation of S15000 APN Number Occupancy Type P Y YP Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (S500). ❑ I, as owner of the property, or my employees with wages as their sole compensadon, 36901026 .03 Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business and Professions Cade: The Contractor's License Law does 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.). ❑ 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 thereon, and . who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law. ❑ I am exempt under Sec B & P C for this reason Owner Date WORKER'S 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 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 required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued ' My Worker's Compensado Insuranc airier and Policynumberare: y7 Cartier.S PolicyNo.: J IJO©�J r —CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is far ane hundred dollars ($100) or less) ' 1 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 forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION 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.) Lender's Name lender's Address I certify that I have read this application and state that the shove information is corecL I agree to comply with ail city and county ordinances and state laws relating to building construction. and hereby authorize 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, 'ud ments, casts and expenses which may in anyway accrue against said City Aco uNT, the granting of this permit. APPLI ANT U AN WILL COMPLY WITH ALL NON -POINT �r j Issued by:S Date SOUR R LATIG . q 0 ` Re -roofs Type of Roof Signatu of ApplicanUContractor Date DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipa ode, Chapter 9.12, and the Health and Safely Code, Section 25532(a)? ❑ Yes a All roofs shall be inspected prior to any roofing material being installed. Will If a roof is installed without first obtainingan inspection', I agree to remove P g the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as d tncd by the Bay Area Air Quality Management all new materials for inspection. District? ❑ Yes o I have mad the hazardous materials requirements under Chapter6.95 of the Califor- niaHe Safety Code, Sections 25505.25533and 25534.1understand that ifthe building does ki. culmmly am . thatflAis my responsibility to notify the occupant of the qui me yvhich mint el