09060082 CITY OF CUPERTINO PERMIT BUILDING DIVISION PERMIT TO
PERMIT NO.
BUILDING ADDRESS:
7412 WILDFLOWER WA TBD - TO BE RTFRMTNFEL_ 09060089
PERMIT ISSUE DATE
OWNER'S NAME:
Q NW
A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
0 0
u O 0 LICENSED CONTRACTOR'S DECLARATION Job Description
V p I hereby affirm that I am licensed under provisions of Chapter 9(commencing
z� with Section 7000)of Division 3 of the Business and Profs ons ode.qnd my license is
"'Co. in full force deflect RE-RF IIJSTL NEW 1/2" PLYWD r LAY 4 0YR GRD ASPHLT
Dnz License Lle x SHNGLS (:LS A 19SQ - VECTOR CONSTRUCTION PD FOR
_p Date Contractor
Ui RCHITECrS DECLARATION BUS
nd nd my 21 s shall be used as public records
'UI<
U LIC
;win Licensed profcssianal
0< OWNER-BUILDER DECLARATION
'< I hereby affirm that I am exempt from the Contractor's License Law for the
Q 0 following mason.(Section 703 L5.Business and Professions Code:Any city or county
n$ru 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 .Ft.Floor Area Valuation
2 that he is licensed pursuant to the provisions of the Contractor's Licerhsc Law(Chapter 9 �q
Y.F- (commencing with Scction 7000)of Division 3 of the Business and Professions Codc)or
on Any violation of 0 0 0
y .. that he is exempt therefrom and the basis for the alleged exemptiOccupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number
net more than five hundred dollars(s500). 36618031 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code: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 arc 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 ik P C for this mason
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-insum for Workers Compen-
-..tion,as provided for by Section 3700 of the Labor Code,for the performance of the
wont 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:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one 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 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 Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z " CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
(1!✓ the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lenders Name
az Lenders Address
U O 1 certify that I have read this application and state that the above information is
IL,'-* correcL 1 agree to comply with all city and county ordinances and state laws relating to
O Vbuilding construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
f.y CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
h`„,CA liabilities,judgments,costs and expenses which may in any way accrue against said City /C r�
(�z in con nee of the granting of this permit. Date r I J J`'
_4
MATERIALS DISCLOSURE Type
Will the applicant or future building occupant storm or handle hazardous material
cc
as defined by the Cupertino Munic al Code.Chapter 9.12,and the Health and Safety
Cole,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 riding occupant use equipment or devices which
it hazardous air contaminants defined by the Bay Area Air Quality Management all ne Materials for inspection.
.strict?
❑Yes ❑No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& afety,Code,Sections 25505,25533 anTW10A hat if building
docs not cu miry have a ant that it is my e t 0
rcquiremcn whir et prior w issu
to beClass'J "or belt r
Owner Datc