06040114:q
CITY OF CUPERTIPIOA
BUILDING DIVISION PER*'y
BUILDING ADDRESS:
DOUGLAS ROSS CONSTRUCTION
NG' 0 6 0 4 0114
10080 WOLFE RD
OWNER'
909 ALMA ST
06.01Z2006
PHONE:
SANITARY NO. CONTROL NO.
(650) 70--700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 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.
REVISE RETAINING WALLS @ VALLCO/BLDG A
LicenscCl ;: Li=.>+ ;
Date („z_r — ��.
ORIG PERMIT #04030151-NO NEW PERMIT
ARCHITECTS DECLAR lON
TS DGCL
1 understand my plans shall be used as public records
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby alTtrm 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 construcL, alter, improve. demolish, or repair any structure
prior to its issuance, also requires the applicant for such permh to file a signed statement
Sq. Ft. Floor Area
Valuation 0
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
pDRpN� jN��`7}�ru1 81
31-62 V 084.00
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (8500).
[11. as owner of the property, or my employees with wages as their sole compensation,
e
Required Inspections
will do the work. and the structure is not intended oroffered for sake (Sec.7044,Business
and Professions Code: Ile Contractors License Law does not apply to an owner of
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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. IL
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. 7044. Business and Professions Code:) The Contractors Li.
cense Law does 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 Contractors
'
License Law.
❑ I am exempt under Sec B & P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain 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 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. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Chis section need not be completed if the permit is for tint hundred dollars (S [00)
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 Workers Compensation provisions of the Labor Codc, you must
forthwith comply with such provisions or this 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
I certify that I have read this application and stale that the above information is
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correct. 1 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 upnn 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.
r
Re-roofs
Type of Roof
Signaturcol'ApplicarldCo—nip6tor Date
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, zs53z(a)?
All roofs shall be inspected to any roofing material being installed.
Yes No
❑ Ya
El
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant tir futu uilding occupant use equipment or devices which
emit haranlous air contaminants as fined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes o
I have read the ardaus malcn requirements under Chapter 6.95 of the Califor-
nia HcaNh & Safcty C. Sections 25505, 533 and 25534.1 understand that if the building
Dare