07090140t§
CITE' OF CUPERTI:
BUILDING DIVISION
BUILDING ADDRESS:
?R'S NAME:
ARCHITECT/ENGINEER:
PERMIT
LICENSED CONTRACTOR'S UPULARAt tun
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 Lia ri
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
Licensed I'micssional
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 w 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 (5500).
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 Contractors 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. If,
however, ){re building or improvement is sold within one year of completion, the owner -
builder yrill have the burden of proving that he did not build or improve for purpose of
as owner of the property, am exclusively contracting with licensed Contractors to
nstntct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law docs not apply to an owner of proqV6 who builds or improves thereon, and
who contracts for such projects with a con r(s) licensed pursuant to the Contractor's
License Law.
I am exempt under Sec B & P C for this reason
:r —
___.__ __. a Dale
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=of
DECLARATION
I hereby affirm u natty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's 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 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hun dollars ($100)
or less.)
I certify that in the performance of the work for which thi it is issued. I shall not
employ any person in any manner so as to become sub' t Workers' Compensation
ws of Calif _
Applicant
NOTICE TO APM354M If, Certificate of Exemption, you should
become subject to the Workers Com tion provisions of the Labor Code, you must
forthwith comply with such provisio is 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.)
Lender's Name
Lenders Address
1 certify that I have read this application and state that the 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 harml the City of Cupertino against
liabilities, judgments, costs and expenses which m any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND W COMPLY WITH ALL NON -POINT
BUSINESS SPACE; STRUC+I.Description
Issued by:
/off/O 7 I Re -roofs
HaS MATERIALS DISCLOSURE
Will the applic r building occupant store or handle hazardous material
ieftned by the Cupertino Municipal, Code. Chapter 9.12, and the Health and Safety
e, Section 25532(a)?
Yes o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as cfincd by the Bay Area Air Quality Management
District?
Yes o
1 have mad the hazardous materials requirements un to 6.95 of the Califor-
niaHealth&SafetyCode,Scctions25505,25533and rstandthatifthcbuilding
docs not currently have a tenant, that it is my try to notify the occupant of the
rcuuirements a pn a Certificate of Occupancy. f
No
Owner or authorized agcne _ Date
iq. Ft. Floor Area
Valuation
umber I Occupancy Type
Required Inspections
Type of Roof
All roofs :;hall be inspected prior to any roofing material being installed.
If a roof i:; installed without first obtaining an inspection, I agree to remove
all new m 3terials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better