09050028N OF CUPERTINO
BUILDING DIVISION PERNUT
BU
PERMIT NO.
OWNER'S NAME:
ARCHITEGT/ENGTNEER:
1 o a LICENSED CONTRACTOR'S DECLARATION
l hecby drttrm that I am Ikenunder provisions of Chapter 9 (commencing
- with Section 1009) of Division 3 of the Budnnw std Professions Code, and my license is
y zin full ro ere and erfect. It O�
License Class Lk.1
qqa Date Contractor
3 ~ RCHF EC 'S DEC A ON
f I u dmstand y p shall he used u public records
),U
c 4. Licensed Professional
9 0 OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contracors Uccase Law for the
p o�C following reason. (Sccdm 7031.5, Business and Professions Code: Any city or courtly
$ (i which mquires a permit to cnntnnnc4 alter. improve, demolish, or repair any Lructum
Y prior to its issuance, also requires the applicant for such permit to file a signed swdaent
this he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
S (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged eumption. Any violar�on of
Section 7031.5 by arty applicant for a permit subjects the applicant to a Civil penalty of
not mote than five hundred dollars (SSOOi
❑ L as owner of the property, or my employees with wages as their sale compamdon,
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
fly who builds or improves thecon, and who does such work himself or through his
own employers, provided that such improvements are not (niendmi or offered for sale. If.
however. the building or Improvement is sold within one year of compkilon. the Owner -
builder will have the birder of proving that bc did not build or improve for purpose of
sale.).
❑ L as owner of the property, am exclusively contracting with licensed wntroctots to
construct the project (See. 70". Business sad Professim Code:) TLe Contractor's L l-
cenw Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors
L4cm= saw.
❑ I am exempt under See. , B k P C for this reason
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 -Insure for workers Compen-
sadon, as provided for by Section 3700 of the Labor Code, for the performance or the
work for which this permit is Lssutel
❑ i have and will maintain Workers Compensation Irmtrsrtce, as required by Section
3700 of the Labor Code, for the performance of the wok for which this permit is issued.
MY Work:' C
COMP ATION INSURANCE
Ohis section need not be completed if the permit is for one hundred dollars ($I00)
Of less)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person In any maaner so is to become subject to the Workers' Compensation
Lam of Califomia Date
Applicant
NOTICE To APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
Oforehwith comply with such provisions or this permit shall be dcancd revoked.
CONSTRUCTION LENDING AGENCY
Eve ram-. 1 hereby affirm that there is t construcdtm Lending agency for the performance of
p; > the work for which this permit is issued (Sec. 3097, CH. Q
WGI. Q Lenders me Na
Lrmdees Address
U O 1 certify that I have read this application and state that the above information is
OEcorrect- I agree to comply with all city sad county ordinances and stale laws relating to
SVbuilding construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposes
f7. (We) agree to saw, indemnify and keep harmless the City of Cupertino against
fn liabilities. Judgments, costs and expenses w 'ch may in any way accrue against said City
U 7 In consequence of the grantin
APPLICANT UNDER S COMPLY WiTH ALL NON -POINT
SOURCE REGULATi
Signature of Appl Dare
U
the applicant orfuture building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. sad the Health and Safety
Code, section 25532(a)a
❑ Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants u dc0n cd by the Bay Area Air Quality Management
District?
0 Yes o
1 have read the hazardous rtue under Chapter 6.95 of the Califor-
ma Heslthsir Safety C 505, 533 and 255341 urdcrstarnd the U site building
n re donot cundy vc a It' y mvo�bil iy to notify the ocevpant of the
mquincmctris w m t Y1,ancy.
omu t 00
(408)996-2
HOUSE DEMO 100 SQ FT
Sq. Ft. Floor Area
umber
35704010.00
Issued by:
Re -roofs
Type of Roof
PERMIT ISSUE
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
Required Inspections
Valuation
T 1pe
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class 'A' or better
Owner or