07040179 CITY OF CUPERTINON .
BUILDING DIVISION PERMIT ..
BUTLDI DDRESS: PERMIT NO.
U�05 VICKSBURG DR TBD TO BE DETERMINED 07040179
OWNER'
10/02/2007
PHONE: - SANITARY NO. CONTROL NO.
ARCHifECT/ENGiNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB - MECH
p a LICENSED cON7RAC OR'S DECLARATION - Job Description
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 70DO)of Division 3 of the Business and Professions Code,and my license is ADD: 698 ' , LIVING SPACE IN (e) SINGLE—STORY RES.
=H in full force and effect
�? License aass --ant#� INCL. 1 MASTER BEDROOM W/ FULL BATH, 1 REG.
p Dater �% t
A cHffE SDEC1ARATION BEDROOM, 1 FULL BATH & KITCHEN REMODEL
a—t I understand my plans shall be used as public records
�d
yV
LO H Licensed Professional
rn OWNER-BUILDER DECLARATION
1 hereby afrrrm that 1 am exempt from the Contractor's License Law for the
cap o following reason.(Section 7031.5,Business and Professions Code:Any city or county
_9 which requires a permit to construct,alter.improve,demolish,or repair any structure
=y prior to is issuance,also requires the applicant for such permit to file a signed statement
S` that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 - Sq.Ft.Floor Area Valuation
i F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $14 9 6 3 0
!�$ that he is exempt therefrom and the basis for the alleged exemption.My vtolalion of - _ I
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of t�Number Occupancy Type 1
not more than live hundred dollars(S500). 36907009` U
❑I,as owner or the property,or my employees with wages as their sole compensation,.
win do the work,and the mcrareis not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:ilex Contractor's License Law does not apply to an owner of Q p
property who builds or improves thereon,and who does such work himself or through his
own employers,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 owmer-
builder will have the burden of proving that he did not build or Improve for purpose of
sale.).
j I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sm 7044.Business and Professions Code:)The Contractor's Li-
ccrue Law does not apply to an owner of property who builds or improves thereon.and.
who contracts for such pmjecu with a contractors)B«ruedsu purant to the Contractor's
License Law.
❑lam exempt under Sec. ,B&P C for this reason
Owner —! I �_ �-� Date t'—
WORKERS COMPENSATION DECLARATION
1 hereby&(firm under penalty of perjury one of the following dedaradons:
❑L have and will maintain a Certi role 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 Worker's Compensation Insurance,as required by Section -
3700 or the Labor Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE _
(This section raced trot be completed if the permit is for one hundred dollars(SI00) -
or lest)
I certify that in the performance of the work for which this permit is issued 1 shall not
employ any person in any mann r s zs a become subject a the workers'Compensation
Laws of California.
this Certificate of Exemption,yod should
become subject to the Workers Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revolve
CONSTRUCTION LENDING AGENCY. -
[--r►rA-. T hereby drum that there is a construction lending agency for the performance of
{Y.> the work for which this permit is issued(Sec.3097,Civ.C.)
WCs+ Q Lender's Name
Z Lenders Address
V 1 certify that 1 have read this application and state that the above information is
ly correct I agree to comply with all city and county ordinances and state laws relating to
0 V building construction.and hereby authorize representatives of this city to enter upon the
W ahovc-mentioned property for inspection purposes.
GI. (We)agree to save,indemnify and keep harmless the City or Cupertino against
to liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
APPLICANT UNDER ANDS AND WILL COMPLY WiTH ALL NON-POINT Issued by: Date SOURCE
REGq S.
l r'� .2 Q Re-roofs
Signature of `- Date
HAZARDOUS MATERIALS DISCLOSURE Type of
Will the applicant or rutuac building occupant store or handle hazardous marcrial
as defined by the Cupertino Municipal Code.Chapter 9.IZ and the Health and Safety
Code.Section25S32(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
Will the applicant or future building If a roof is installed without first obtaining an inspection,I agree to remove
pp g occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. .
District]
❑Yes El No
I have read the hazardous rnatcrials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and]5534.I understand that if the building -
does not currently have a tenant.Chart is my rsporno i ity to nodry the occupant of the
requirements which must be
Date