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BUILDING DIVISION PER
BUILDING ADDRESS:
OWNER'S NAME:
MARILYN S
PHONE:
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
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§,�adcecB
e ffn i "�, i
LicensLic. p T J
Date Z ' Contractor
ARCHITECTS DECLARATION
I understand ray�ens shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 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 construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file 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 ahcged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant W a civil penalty of
not more than five hundred dollars (5500).
❑ 1, as owner of the property, or my employers with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law docs 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 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.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the pmject (Sec. 7044, Business and Professions Code:) The Contractor's Li-
ccnse Law docs 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
4nse Law.
am exempt under Sec. — , B & P C for this reason
Owner
Date
WORKER'S COMPENSATION DELLA
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 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.
❑ I have and will maintain Workcrs 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:
Camey Policy No.:
me CERTIFICATE OF EXEMPTION FROM RKERS'
COMPENSATION 114SU
(This section need not be completed if permit is for one hundred dollars (E 100)
or less.)
1 certify that in the performance of the work for w ich this permit is issued, 1 shall not
employ any rson in _ m !r to bee bject to (he Workers'Compensation
Laws of lifo tic '1
Appl'
N E aking this Certificate of Exemption, you should
bee tliyecI to the orker's mpensation provisions of the Labor Code, you must
ford comply with isiors or :his 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
Lender's Address
1 certify that 1 have read this application and state that the above information is
coffecL 1 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
ahove-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
SOU U,�LATT
11-2—a
SignatffrcgApplicant/Conurabipr Date
HAZARDO US MATERIALS DISCLOSURB-�
Will the applicant or future building occupant store or handle hayardous 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 or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes No
I have read the hazardous materials requiremem s under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and25534. I understand that if the building
d currently have Inapt drat it is my responsibility to notify the occupant of thc
uire
is,
-i hist to
rior to issuance of a Certificate of Occupancy.
t I =�Z - o
OWnEr-br authorized age Date
MARILYN LYN SCHERMERHORN I PERMIT Ncb 4110 014
PERMIT ESUS DATE
SANITARY NO.
Job Description
REVISION --ELECT.
NO NEW PERMIT ISSUED/ ORIG. 404060210
CONTRACTOR: BT CONSTRUCTION
Ft. Floor Area
Issued by:
Re -roofs
Type of Roof
Required Inspections
CONTROL NO.
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 "B" or better