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OF
CITY OF CUPERTINO
DIVISION PERMIT
�� IVl�lY gl?311�r
BUILDING
BU" Ifg1� "hEGNART RD
VIA BUILDERS INC.
PERMIT
O7O9O124
SANITARY NO. CONTROL NO.
(650)948-1077
ARCHITECf(ENGINEER:
BUILDING PERMIT INFO
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
S FDWL — 2 STORY 5,263' LIVING , PATIO 340', GARAGE
in full force and effect.
License Class Lic. #
858'
Date Contractor
ARCHITECTS DECLARATION
,
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I 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 mquires the applicant for such permit to file a signed statement
Contractor's License law (Chapter 9
Sq. Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the
Profusions Code)
$1330973
(commencing with Section 7000) of Division 3 of the Business and 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 penally ofNumber
3 6 6 4 7 015 �� Occupancy Type
not more than rive hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure isnot intended oroffered for sale (Sec.7044,Business
Required Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
9 P
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. If,
however, th "Iding or improvement is sold within one year of completion, the owner -
builder have the burden of proving that he did not build or improve for purpose of
sale.)
. as owner of the property, am exclusively contracting with licensed contractors to
onstrohx the project (Sec. 7044, Business and Profusions 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 contractors) licensed pursuant to the Contractor's
License Law.
❑ ]am em r Sec . B & P C for this reason
Owner Datl�
WORKER'S C MPENS N DECI.A ATION OF
I hereby affirm under ty of pe ury one of the following declarations:
❑ 1 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 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 (S IDD)
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 mann�m • jcct to the Workeri Compensation
Laws of Califaud. D
Applicant
NOTICE TO AOPUCAA after mjgng this Certificate of Exemption, you should
become subject to the Wo is Compensation provisions 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 construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Lender's Name
r Lender's Address
j I certify that I have road 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 authorim representatives of this city to enter upon the
above-mentioned property for inspection purposes.
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
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liabilities, judgments, costs and expenses which may in any way accrue against said City
r in consequence of the granting of this permit,
APPLICANT UNDEJ19TANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE EGU NS.
121
Re -roofs
Signature of Appl' -/Contractor Data
HAZARD MATE LS DISCLOSURE
Type of Roof
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)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yu o
If a roof is installed without first obtaining an inspection,agree to remove
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
.I
all new materials for inspection.
District?
❑ Yes
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health& Safety Cede, Sections 25505, 25533 and 25534.1 understand thatif the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requimens h mel prio i ran of a Ccnifhcatc of etre
Signature of Applicant Date
, ®7
All roof coverings to be Class "B" or better
Owner or out oriztd agcnl