08030006BUILDING DIVISION PERAUT
BUIL-ADDRESS: G D1�DRESS: PERMrr NO.
TNOOb1 BUBB RD OPI COMMERCIAL BUILDERS 08030006
445 LEIGH AVE 03/21/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHITECI'/ENGINEER: BUILDING PER O
REVISE LANDSCAPE AREA @BUBB BLDG ELECT'PLUMB
MECH
O 0 LICENSED CONTRACT'OR'S DECLARATION
U 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z 'UJ with Section 7000) of Division 3 of the Business and Professions Code, and my license is
Oin full force and effect.
Y License Class Lic. N
I:,n Date Contractor
' 19 ARCHITECTS DECLARATION
I understand my plans shall be used as public records
yU
a I— Licensed Ptufcssional
0
rn OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
00 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
Z y prior to its issuance, also requires the applicant for such permit to rile 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 rive hundred dollars (5500).
❑ I, as owner of the propetty, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7144, Business
and Professions Code: The Contractors License Law does not apply to an owner of
properly who builds or improves thereon, and who does such work himself or through his
own employers, 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.).
P 1, 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 does not apply to an owner of properly who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law,
❑ I amAexempt under S G , B & P
C for this mason
Owner T
Date 71 65
ON DECLARATION
1 hereby affirm under penalty rjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compcn-
sation, as provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ 1 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 Worker's Compensation insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for 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
rtcam of Ex5emption, you should
become subject to the Worker's Compcnsatio sions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructinn 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 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 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.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
S
3/ -0 rob
Sig licant/Contractof Date
HAZARDdITS 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, Section 25532(a)7
❑Yes ANo
Will the applicant of future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes 1§Nu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & SafctyCodc, Sections 25505,2 5533 and 25534.1 understand that if the building
does not currently have a ant, that it is my responsibility to notify the occupant of the
requ Certifie p cy.
Date
ob Description
Sq. Ft. Floor
APN N
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy
Date
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'W' or better