09060133 CITY OF CUPERTINOr pT
BUILDING DIVISION PERT
BUILDING ADDRESS: PERMIT NO.
SIGNS
OWNER'S NAME: PERMIT ISSUE DATE
PH A �009CONTROL NO.
(408) 9U__96
ARCHrrECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
u O p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I 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
�::iy in full force and �j 1 SET OF CHANNL LETTERS W/HALO LIGHTING.
y Date Contractor
ARCHITECTS DECLA
g U 1 understand my tans shall be used as public reco
a
o w Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
is O O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
4 m ff which requires a permit to construct.alter,improve,demolish,or repair any structure
M y 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
Xt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y .. that he is exempt therefrom and the basis for the alleged exemption.Any violation of $4800
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($500)
❑1,as owner of the property,or my employees with wages as their sole compensation, 36955082 . 0 2
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 does not 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 Cole:)The Contractor's u.
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.
C]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:
❑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.
❑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'
FRO
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 Workcrs'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 Libor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
z'" CONSTRUCTION LENDING AGENCY
(�rA 1 hereby affirm that there is a construction lending agency for the performance of
pG the work for which this permit is issued(Sec.3097,Civ.C.)
a Q a
Lender's Nme
Lender's Address
U I certify that I have read this application and state that the above information is
Iy correct.I agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorize representatives of this city to enter upon the
aabove-mentioned 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
U Z in consequence of the granting of this permit.
r"r APPLICANT UNDERSTdke�
Da
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 ;hall be inspected prior to any roofing material being installed.
❑Yes Gb No
Will the applicant or future building occupant use equipment or devices which
If a roof i;installed without first obtaining an inspection,I agree to remove
MR hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑ u
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 'ding
Date All roof coverings to be Class'%"or better