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CITY OF CUPERTINO
BUILDING DIVISION PERMIT T
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BUIL G D ESS:
`�S4�t� SAN JUAN RD
ERNIE ALTMAN CONSTRUCTION,
PERMIT NO.
07070050
4047 1ST ST STE 109
07/18/2007
PHONE:
SANITARY NO. CONTROL NO.
(925) 577-3441
ARCHITECT/ENGINEER:
BUILDING PERMrriNFo
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I 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
REV I S I ON -FOUNDATION , OR I G PERMIT #06050101 NO NEW
in full force and effecL
License Class Lic. N
PERMIT
Date Contractor
ARCHITECTS DECLARATION
I understand my plans sball he used as public records
'
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alum 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
he is to of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area0
Valuation
that licensed pursuant the provisions
(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
Number
34218044 '
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of�,pj�j
not more than five hundred dollars ($500).
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❑ I, as owner of the property, or my employers with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered forsale (Sec. 7044, Business
and Professions Code: The Contractor's License Law dots not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. lf.
however, the building or improvement is sold within one year of completion, the owner -
he did build improve for
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builder will have the burden of proving that not or purpose of
sal 94.
FI, as owner of the property, am exclusively contracting with licensed conttaerais to
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nstruct the project (Sec. 7044, Business and Professions Code:) The Contractor's 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.
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❑ I am eXempt under Sec , B & P C for 's reason
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Owned 1 q `� Date -7 0-7
�'� WORKER'S (CLOMP 'ATION DECLARATION
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1 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
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work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
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3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Polity number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(7nis section need notbc completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the wo k for which this permit is issued, I shall not
employ any person in any man, .to e�ormsubjcct to the Workers' Compensation
'
Laws of C,hi .ia. �atc
Applicatfi
NOTICE A PIt.1CANT. If, airterdnaking gFis Certificate of Exemption, you should
become subject to the Worker's Co nation provisions of the Labor Code, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
I
1 CONSTRUCTION LENDING AGENCY
c I hereby af0mc 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
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
c building construction, and hereby authorise representatives of Nis city to enter upon the
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above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
1 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
Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Type of Roof
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1&tnitut of Applicant/ ntractor ate
H RDO h1ATERIALSDISCLOSURE
Will the applicant or future building occupantstorc or handle hazardous material
as defined by the Cupertino Munic' al Cade. 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 Nu
If a roof is installed without first obtaining an inspection, I agree to remove -
Will the applicant or future building occupant use equipment or devices which
cmit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes RJu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
re 'reme its which be
must met prior to issuance of a Ccnilicate of j a
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owncr
r authorized a t Date