08110059BUILDING DIVISION PERMIT
OWNER'S NAME:
ARCHITEC IENGTNEER:
O p LICENSED CONTRACTOR'S DECLARATION
'r2 enti 1 hereby affirm that 1 an limnsed under provisions of Chapter 9 (commencing
_ with Section 7000) of Divislon 3 of the Business and Professions Code, and my items is
n 7 w in full force and eff, 0
3 Licenac Lk. x
n F, Date V Contractor
RATIO
ARCHTTECrS DECLAN
`` I understand my plans shall be used as public records
3WU
it o � Licensed Professional
50— OWNER -BUILDER DECLARATION
+� � 2 1 hereby aI ,,m that 1 em exempt from the Contractor's License Law ror the
O O rollowing reason. (Section 70313, 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
= G that he is licensed pursuant to the provisions of the Conuacmrs License Law (Chapter 9
t- $ (commencing with Section 7000) of Division 3 of tho Business and Profession Codc) or
that he is exempt thermfrom and the basis for the alleged exemption. Any violation of
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (3500).
❑ L as owner of the property, or my employees with wages as their sole compensation,
wilt 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
mw 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 wilt have the burden of proving that be did not build or improve for purpose of
sale.).
❑ L as owner of the property, am =clualvely contracting with licensed wnuactors to
construct the project (Sec 7044. Business and Professions Code:) The Cormsictors Li.
cense Law does not apply to in owner of property who builds or impovea thereon, and
who contracts for such project/ with a conuactor(s) licensed pursuant to the Conusetees
Lhcenas Law.
❑ 1 an exempt under Sec B k P C for this reason
Owner Due
WORKER'S COMPENSA71ON DECLARATION
1 hereby affirm miler penalty of perjury aro of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self Insue for Workers Compen.
-ti . as provided for by Section 3700 of the Labor code, for the performance of the
work for which this permit is issued.
71 have and will maintain Workers Compensation lawrancc, as required by Section
700 of the Labor Code, for dee perform&= of the work for which this permit is Issued
My Workers Compensation Insurance artier and Policy number are: p
Cartier.A 1 67 Polky Na: 3 k'4
CERTIFICATE 5F—EKEUPMON FROM WORKERS'
COMPENSA77ON INSURANCE
('this section need not be completed U the permit is forone hundred dollars (3100)
or las.)
I certify that In the prformance of the work ror which this permit is issued, l shill not
employ any person in any manner so as to become subject to the Worked Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption. you should
become subject to the Workers Compensation provisions of the Labor Code, you must
.J O rorLbwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
E+ " 1 herby affirm that there is s construction lending agency for the performance of
a > the work for which this permit is issued (Sec 3097, CN. C.)
W Q LendersName
z Lcmices Address
U O 1 cwtify that t have read this application and stem that the show information is
u correct. I agree to empty with all city and county ordinances and state Laws relating to
O building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for uWenlon purposes.
(We) agree to saw. indemnify and keep harmless the City of Cupertino against
,.., 14 liabilities, Judgments, costs and expenses which may Ire arty way accrue against said City
(i 7 in consequence of the granting of this permit.
G� APPUCANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULAI7�
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupants me or handle hazardous material
as defined by the CupaUm Municipal Code. Chapter 9.12, and the Health and Safety
Code .Soo 'on 25532(x)7
❑ Yes
Will the applicant or future building occupant use equipment or devises which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District]
❑ Yes / 0o
1 have mad the hazardous materials requirements under chapter 6.95 of the Califor-
nia Health k Sarety Code, Sections 25505.25533 and 25534. I undcalmud thatif the balding
does not currently have a remnm, that it is my respot tfflity lonotify dnc occupant of the
requitemens which must be ret prior to issuance of a Certificate of Occupancy.
�ri7oioq
Owner or authorized agent Date
408)867-055
rt-KMI I avU.
PERh4T ISSUE DATE
CONTROL NO.
BURRING PERMIT MFO
BLDO ELECT PLUMB
Job Description
INSTL FLUSHED ROOF MOUNTED SOLAR MODULES—PAINT
FLASHING/TRIM TO MATCH ROOF COLOR.
Sq. Ft. Floor Area
2
37509009.00
Required Inspections
Issued by:.
Re -roofs
Type of Roof
Type
Date 2
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 materials for inspection.
Signature of Applicant Date
. All roof coverings to be Class's' or better