09060055 CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT L95UE DATE
SHO
FA13 2 A �009 CONTROL NO.
(408) 250-6672
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o p LICENSED CONTRACTOR'S DECLARATION Job Description
u(= I 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
y in full force and cffecL REPLC WATER HEATER
j rn Z License Class Lic•N
F Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
�yU
W w Licensed Professional
n y� OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
i O O following reason.(Section 703 L5,Business and Professions Code:Any city or county
k'-*Pi which requires a permit to construct.alter,improve,demolish,or repair any structure
Z- prior to its issuance,also requires the applicant for such permit to file a signed statement
F=C that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
yt,$ (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 or
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).
C1 1,as owner of the property,or my employees with wages as their sole compensation, 36638016 . 0 0
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q
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
sak.).
tI,as owner of the property.am exclusively contracting with licensed contractors to
onstruct the project(Sec.7044,Business and Professions Code:)The contractnes u.
c 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 Contractors
License Law.
❑I am exempt under Sec ,B&P C for this reason
Owner Date
^CLARAT10
I hereby affirm under penalty of perjury one of the fallowing declarations:
I have and will maintain a Certificate of Consent to self-insum far Workers Compen-
on,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 Workces 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 EXEMP'T'ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if tbe permit is for anc hundred dollars($100)
or Icss)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in anyJouner so asw tor
subject to the Workers'Compensadon
Laws of
f cmption, u 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 R CONSTRUCTION LENDING AGENCY
[� I hereby affirm that there is a constriction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Lenders Address
I)C) I certify that I have read this application and state that the above information is
corccL 1 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
a 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
U Z in consequence of the granting of this permit.:
-' APPLICANT UNDER NDS AND W)d COMPLY WITH ALL N N-P INT Issued by: Date
SOURCE
d Re-roofs
Signature A li ontractor Da
g HAZARDOUS MATERIALS DISCLOSU Type of Loof
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.
[:1 Yes No
Will the applicant or future building occupant use equipment or devices which
If a roof:s installed without first obtaining an inspection,I agree to remove
tt hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
rict?
❑Yes KO
No
1 have read the hasardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does no�ndyh ant.that it is my responsibility to notify the accts t of the
reyuircmet m isaaanee ora cenifieate art Ocea Signature of Applicant Date
re All roof coverings to be Class'n"or better