07090031BUILDING DIVISION PERAUT
PERMIT N0.
BUILD
(jJC,h,99RTSSN BLANEY AVE TBD TO BE DETERMINED 07090031
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER
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LICENSED CONTRACTOR'S DECLARATION
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0
E- I hereby affirm that ! am licensed undo provisions of Chapter 9 (commencing
Z U with Section 7000) of Division 3 of the Business and Professions Code, and my license is
w in.full force and effect 4-51
�? License 1 s Lic.#
E, Date Contractor
a - ARCHITECT'S DECLARATION
11-4 ,;, t understan my ans shall he used as public records
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m y LPMKsed mfcss n
iOWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
qO following reason. (Section 703 1.5, 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 Glc 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
3 m 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).
0 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work- and the structure isnot intended or offered forsake (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 notintended 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.).
0 I, 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 dors not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec. , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
0 I have and will maintain a Certificate of Conscnt 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.
�.rhave 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' Co peosation Insurance carrier and Policy number am:
Carrier. _3 t Policy No.: J V/eQ5 eA
CERTIFI ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far 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 become subject to the Workers' Compensation
Laws of California. Date
Applicant .
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
Z forthwith comply with such provisions or this permil shall be deemed revoked.
7-- CONSTRUCTION LENDING AGENCY
P: tom. I hereby affirm that there is a construction lending agency for the performance of
(4 .7 the work for which this permit is issued (See. 3097, Civ. C.)
W 0 Lender's Name
Z Lender's Address
U 0 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
0building construction, and hereby authorise representatives of this city to enter upon the
U above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Htry liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permil.
t --i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/6- :z.a
Sr of Applicant/Obntractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici al Code, Chapter 9.12, and the Health and Safety
Code, Sccton 25532(a)?
0 Yrs a
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as rncd by the Bay Arca Air Quality Management
District?
❑ Yes u
1 have read the hazardous materials requirements under Chapicr 6.95 of Lhc Califor-
nia Health &Safety Code, Sccdons25505,25533and 25534.1understand ,that ifthc building
docs not currently have a ant. that it is my responsibility to nodl'y the occupant of the
requ� of a Certificate of Occupancy.
iAX -7 e^ --I
Date
PERMIT ISSUE DATE
SANITARY NO. CONTROL
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
ADD NEW DINING RM. 286 SQ., CONVRT (E) GARG 562
SQ.
Ft. Floor Area
3163010
Issued by:
Re -roofs
Type of Roof
$110000
Required I:,spections
Occupancy 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 "B" or better