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CITY OF CUPERTINO
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BUILDING DIVISION p IT
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BUILDING ADDRESS:
1614 JAMES TOWN DR
CHARLES S CHRAMM
PERMIT NO. 05120030
OWNER'
1 04 2006
PHONE:
SANITARY NO. CONTROL NO.
(408)839-9979
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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 erfeCL
REVISION --SW TO SHEAR WALL
License Class Lie. M
Date contractor
NO NEW PERMIT ISSUED/ORIG. $#05020048
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to concoct, alter. improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Ft. Floor Area
Valuatior$ 2 14
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq.
(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
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
36610067.00
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
ns
Required Inspections
will do the work and the struatire is not intended or offered forsalc (Sec. 7044, Business
and Professions Code: The Contractorse
License Law does not apply to an owner of
Q p
property who builds or improves thereon, and who does such work himself orthrough 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply an owner of property who Wilds or improves thereon, and
who contracts for such pro with a contractors) licensed pursuant to the Contractors
License Law.
❑ lam exempt un Se5 , B & P C for this
/reason
LARATION
I ffr reby a " under penalty of perjury one of the following declarations:
❑ I have an aintain 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 orthe Labor Code, for the performance of the work for which 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 lithe permit Is for one hundred dollars ($100)
or less)
I
I certify that in the rfo a of the work for which this permit Is issued, 1 shall not
employ
E TO APPLI A f r making this Ccnifica of Ex mp'on, you hould
become b'ect Io th Wotker's Compensation provisions of the Llbo Code, you must
forthwith c such provisions or this permit shall be deemed revoked.
CONSTRUCTION TENDING AGENCY
1 hereby affirm thai 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
,
Lender's Address
1 certify that 1 have read this application and state that the above Information is
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building concoction, and hereby authorize representatives of this city to enter upon the
ahove-mcnLioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, coals d expenses which may In any way accrue against said City
in consequence of the mit,
APPL
H ARDOUS MATERIALS DISCLOSl7RE
Will th plic r future building occupant store or handle hazardous material
as defined by the C o Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? �
All roofs shall be inspected prior to any roofing material being installed.
Yes YJrvo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
emit hazardnus air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? _
❑ Yes Q,pto'
Ihave adt hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & ct c. Sections 25505.25533 and 25534. I understand that if the Wilding
does not curt Ilyha a tenant. that it is my responsibility to notify the occupant of the
requirements hi h met prior to issuance of a Cc roes ar•Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owncr ur au *rirod agent e