09070099 CITY OF CUPERTINO
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BUILDING DIVISION PERT F' .
MI
BUILDING ADDRESS: PERMIT NO.
10309 BRITTANY CT TBD - TO BE DE
"INER'S NAME: PERb11T ISSUE DATE
PHONE: SA R CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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a0p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
zty withscorceand0)ocDivision 3ofthe Business and Professions Code,and mylicense is REMODEL 190 SQ FT TO. 150 SQ FT TO KITCHEN, 40 SQ
��y in full force and effect
E—a Date Contractor
Cog FT TO E?ATH, ADD 4 SKYLIGHTS, REPLACE THE ALL
F O Dato Contractor
ARCHITECTS DECLARATION ii� WINDOWS, ADD SINGLE HUNG WINDOWS IN FAM, M. SUITE,
D < I understand my plans shall be used as public records
06U
L O y Licensed Professional
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
e which requires a permit to construct.alter,improve,demolish,or repair any structure
Zy 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
F (commencing with Section 70D0)of Division 3 of the Business and Professions Code)or 3 O O O 0
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 mom than fire hundred dollars(M). 36930018. 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 docs 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 will have the burden of proving that he did not build or improve for purpose of
sale.).
011.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 docs not apply to an owner of property who builds or improves thereon,and,
who conuacts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Spec B&Py,C for this mason.�
Date�u� yJ_
WORKER'S COMPENSATION DECLARATION JJ
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.
❑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 Compensation Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section treed 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,1 shall not
employ any person in any manner so u to bccomo subject to the Workers'Compensation
Laws of California.Date 7t—
Applicant
NOTICE TO APPLI�: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 h--h CONSTRUCTION LENDING AGENCY
[~-h I hereby affirm that there is a construction lending agency for the performance of
IY. the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
2 Lender's Address
U C 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
0 V building concoction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
„Fy liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit, y Date /✓�(/"�t/
"r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b
SOURCE REGULATIONS.
?►^/�-- -�-.f0-D 9 Re-roofs
Signature o ppli t/Contractor D� at -�
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
1c,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes 1 '140
Will the applicant or ffuut`ure 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 as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes A]No
I have read the hazardt'wss materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building 0 D
does not currently have a tenant that it is my responsibility to notify the occupant of the
requirements which mast be met prior to issuance of a Certificate of Occupancy. Signature of Appl leant Date
ZM-1! -7- 10-04 All roof coverings to be Class'A"or better
Owner or authon.cz E a nl tc