09060160 -777777777777777777
CITY OF CUPERTINO
BUILDING DIVISION PERMITd� TR�� TR
PERMIT NO.
BUILDING ADDRESS:
l' .
OWNER'S NAME: SERVICES' PERMIT LSSUE DATE
A CONTROL NO.
.H0
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDGELECT PLUMB MECH
a 0 0 a
u o o LICENSED CONTRACTOR'S DECLARATION Job Description
mI hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
=y in fullforeeand ell . —, RE-ROOF REMOVE EXISTING SHAKE ROOF AND .INSTALL 1
jLicense ass Lle•* - -
Fo pato �' Contractor / P4 S4• a�u- LAYER 3 ) LB 280 FELT 40 YR COMP 28 SQUARES
ARCHITECTS DECLARATION
reI < I understand my plans shall be used as public records
DWU
L6 H Licensed Professional
L.0:1� OWNER-BUILDER DECLARATION
gI hereby affirm that 1 am exempt from the Contractor's License Law for the
p O following mason.(Section 7031.5,Business and Professions Code:Any city or county
m which requires a permit to construct,alter,improve,demolish,or repair any structure
_ prior to its issuance,also requires die applicant for such permit to file a signed statement Valuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
r$ (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
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(5500)_ 35922048 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
wiU do the work.and the structure is not intended or offered for sale(See.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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 wiU 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 U.
cense Caw does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contiactor(s)licensed pursuant to the Contractors
License Caw.
❑I am exempt under See 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's Compensation Insurance carrier and Policynumber are:
Cartier. �L1.•Ity &41Policy No.j_361290UZCJ7U
CERTIFICATE OF EXEMPTION 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 Workcrs'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z 0-4 CONSTRUCTION LENDING AGENCY
[~i Ln I hereby affirm that there is a construction lending agency for the performance of
a> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
124 Lender's Address
V 0 I certify that I have read this application and state that the above information is
LL h� corteCL I agree to comply with all city and county ordinances and stale laws relating to
0 Fbuilding construction,and hereby authorize representatives of this city to enter upon the
U above-mcndoned property for inspection purposes.
Oe (We)agree to save,indemnify and keep harmless the City of Cupertino against
h t 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. Date
►+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
SOURCE R G L ONS.
/
DateT of
MATERIALS DISCLOSURE Type
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.
❑Yes No
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 rr aterials for inspection.
District?
C]Yes 010
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 V
does not currently have a tenant,that it is my responsibility to notify the occupant of the
requirements ich must be mel prior to issuance of a Certificate of Occupancy. Date
All roof coverings to be Class'."or better
Owner Date