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0711000400 Z , W "•� rsr Q �Z UO wH OV W U LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect. License Class Lic• X Date Contractor ARCHITECTS DECLARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's 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 signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (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 exemption Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 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 and Professions Code: The Contractor's License Law does not apply to an owner of 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. lf. 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 ATTIC REMODEL Job Description F_ Sq. Ft. Floor Area I $133493 Valuation 01, 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 does not apply o an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Conu=oes License Law. ❑ I am exempt under See B & P C for this mason Owner JHS 2� Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: r] I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- 'ion, as provided for by Section 3700 of the Labor Code, for the performance of the rk 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 are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need rot 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. I shall not employ any person in any manner so as to bcqDgw ser t o W kers' Compensation Laws of Califoa{ia Dam_ Applicant NOTICE TOAPPLICANT-. If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Cade, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constructinn lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name — Lcndees Address 1 certify that I have read this application and suite that the above information is corecL I agree to comply with all city and county ordinances and state laws relating to building construction. and hereby authorise 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOU REGU� O� Signature of Applicant/Contractor Dare HAZARDOUS MATERIALS DISCLOSURE 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 Code, Section 25532(a)7 ,�.- ❑ Yes IJ N. Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management listrict? ❑ Yes ❑ No I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant. that it is my responsibility to notify the occupant of the requr ts which must be met prior o issuance of a Certificate of Occupancy. . ter-! _�- //- 2-/ - O Owner or authorized Date 35625017`. Issued by Re -roofs Occupancy Type Required Inspections Type of R oof 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 rr aterials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better PERMIT NO. 07110004 PERMIT ISSUE DATE 11/21/2007 SANITARY NO. CONTROL NO. BUILDING PERMIT INFO BLDG ELECT PLUMB Job Description F_ Sq. Ft. Floor Area I $133493 Valuation 01, 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 does not apply o an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Conu=oes License Law. ❑ I am exempt under See B & P C for this mason Owner JHS 2� Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: r] I have and will maintain a Certificate of Consent to self -insure for Worker's Compen- 'ion, as provided for by Section 3700 of the Labor Code, for the performance of the rk 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 are: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need rot 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. I shall not employ any person in any manner so as to bcqDgw ser t o W kers' Compensation Laws of Califoa{ia Dam_ Applicant NOTICE TOAPPLICANT-. If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Cade, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constructinn lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. C.) Lender's Name — Lcndees Address 1 certify that I have read this application and suite that the above information is corecL I agree to comply with all city and county ordinances and state laws relating to building construction. and hereby authorise 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 liabilities, judgments, costs and expenses which may in any way accrue against said City in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOU REGU� O� Signature of Applicant/Contractor Dare HAZARDOUS MATERIALS DISCLOSURE 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 Code, Section 25532(a)7 ,�.- ❑ Yes IJ N. Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management listrict? ❑ Yes ❑ No I have mad the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health & Safety Cade, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant. that it is my responsibility to notify the occupant of the requr ts which must be met prior o issuance of a Certificate of Occupancy. . ter-! _�- //- 2-/ - O Owner or authorized Date 35625017`. Issued by Re -roofs Occupancy Type Required Inspections Type of R oof 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 rr aterials for inspection. Signature of Applicant Date All roof coverings to be Class "B" or better