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CITY OF CUPERTINO
BUILDING DIVISION PERMITN.
C�1iT]RGTQ'nR�1yIATION
BUILDING ADDRESS:'
PERMIT NO.
7918 OCTOBER WAY
TBD — TO BE DETERMINED
07090010
OWNER'S NAME:
PERM TISSUEDATE
SANTrARY NO. CONTROL NO.
ARC HTTECTIENGI NEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivision 3 ofthc Business and Professions Code. and my liccuscis
SFD—ADD BATHROOM 81 ' —REMODEL RELOCATE KICTHEN TO
in full force and effect
License Class Lic. 0
(E) BEDRM / PLAYRM
Date Contractor
.
ARCHITECTS DECLARATION
1 understand my plans shall he used its public records
Licensed Professional
OWNER -BUILDER DECLARATION
- I hereby affirm that 1 am exempt from the Contractors license Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
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 signet) statement
he is licensed to the the contractors Liunsc Law (Chapter 9
Sq. Ft. Floor Atea Valuation
that pursuant provisions of
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 1 2 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
Number Occupancy Type
not more than five hundred dollars (S500).
36213035 .`�
❑ I, m owner of the property, or my employees with wages as their sole compenssdon,
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
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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.).
14 I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) Tie Contractors U.
censc 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
Lice>11erely
❑ ,BdoOwORKERS
DECLARATION
affirm under penalty of perjury one of the following dcclaruionc
❑ I have 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
work 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 forwhich this permit is Issued
My Workers Compensation Insurance carrier and Policy number are:
Cartier. 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 Tess)
I ccrlifv that in the performance of the work for which this permit is issued. I shall not
employ any person in any amre o b o su je t to th Workers' 'Compensation
Laws of California
Applicant
NOTICE TO APP , after making this Ccrtircate of Exemption, you should
become subject to4hc Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked -
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
' the work for which this permit is issued (Sec. 3097, Civ. C.)
- -
Lenders Name
Lenders Address
I certify that 1 have read this application and state that tlrc above information is
' correct. I agree to comply with all city and county ordinances and state laws relating to
{ building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities judgments, costs and espensrs which may in any way accrue against said City
' in con If th granting of this permiL
+ AP ICA STANDS AND WI COMPLY WITH ALL NON -POINT
Issued by: Date
SO RCE A NS.
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Re -roofs
Si cure o AppIicant/Contractor —w
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as dcfrted by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
to
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant brae equipment or dcvicrs which
emit hazardous air contaminants as dcfrncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yee Po
_materials
I have read the hazardous requirements under Chapter 6.95 of the Califor.
rain. Health $ Safer o c, Sections 25505, 25ffnd34.1 understand mat if dre huilding
does eu a tenant that it is ilfly to notify the occupant of the
requirements
D re