09040010 CITY OF CUPERTINO ��
BUILDING DIVISION PERNIIT
`,..R
BUILDING ADDRESS: PERMIT NO.
930 ROSE BLOSSOM DR TBD - TO BE DETERM
OWNER'S NAME_ PERMIT ISSUE DATE
S CONTROL NO.
ARCHnF=IENGINEER: BURRING PER Mrr INFO
BLDG ELECT' PLUMB - MECH
0 0 0 0
U O p LICENSED CONTRACTOR'S DECLARATION Job Description
K I hereby affirm that I am licensed under provisions of Chapter 9(commencing
!v with Sation 7000)of Division 3 of the Business and Professions Code.and my license is
� N in full foam andcff=LA - ADDITION OF 513 SQ FT TO KITC, LIVING, LAUNDRY &
D n— License
Class_..L�, Lie-0 PANTRY. 421 SQ FT TO ATTACHED GARAGE. REMODEL
�— Datc Contractor
�y ARCHIT EC'rS DECLA TTON ns 1299
a I understand my pla shall be used as public records
P L U Licensed ProfessionalSQ FT. THROUGHOUT.
5° OWNER-BUILDER DECLARATION
n"
I hereby alum that I am exempt from the Contractors License Law for the
p 0p7 following reason.(Section 7071.5,Business and Professions Code:Any city or county
$li which requires a permit to conaruct.alter.improve,demolish,or repair any structure _-
Z` prior to its issuance,also requires the applicant for such permit to file a signed statement
ct that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 7000)of Division 3 of the B usiness and Professions Code)or 160000
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Season 7031-5 by any applicant for a permit subjects the applicant to a coil penalty of APN Number Occupancy Type
not more dun five hundred dollars(S500). 35906028 . 00
❑L 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.70".Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such wort himself or through his
own employees,provided that such improvements are not Intended or offered for sales 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-).
❑L as owner of the property,am exclusively contracting with licensed conbacmrs to
construct the project(Sec 7044.Business and Professions Code:)The Contractors 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 Contractors
License Law-
❑I am exempt under Sec .B&P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
-m and will maintain a Certificate of Consent to self-Insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
wort 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 1s Issued -
My Workers Compensation Insurance carrier and Policy number are: -
Carrier. Policy No.:
CERTIFICATE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
(This scclon need not be completed if the permit Is for one hundred dollars($100)
or less)
I certify that in the performance of work for which this perrrmI shall not
employ any person in any int to the 'on
Laws of California.Dare
Applicant
NOTICE TO APPLICANT:If,alter making this Ceni m on, u should
become subject w the Workers Compensation provisi bpr C you must
,J. z forthwith comply with such provisions or this permit
TI s be d oked
O CONSIAUCON LENDING AGENCY
(-+ 1 hereby M.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' Name
z Lenders Address
U 0 1 certify that 1 have read this application and state that the above information 1s
V. P correct I agree to comply with all city and county ordinances and state laws relating to
C U building construction,and hereby authorize representatives of this city to enter upon the
W abovrmendoned propeny for inspection purposes
Ia. (We)agree to save'
in c nify and keep harmless the City of Cupertino against
t,F'y liabilities,judgments,costs x which may in any way accrue against said
Date
SOUR
DISCLOSURE Type of Roof
Will pl' t or fat building mceupant snore or handle Iwudous material
as defined - upenino unicipal Code.Chapter 9.12,and the Health and Safety v
code.Section 532(a)? All roofs shall be inspected prior to any roofing material being installed.
Cl Yes Ca No _
Will the applicant or future 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 XNo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&SafetyCode•Sections 25M,25533 and 23534.1 understand that if the building
does not currently have a ten my responsibility m notify the occupant of the
requiremen
Da id