07020097yzya
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CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
7954 WOODLARK WY
OWNER'
PHONE:
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70W) of Division 3 of the Business and Professions Code, and my license is
in full force and cffecL
License Class Lic. R
Date Contractor
ARCHITECT'S 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 mason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any structum
prior to its issuance, also requires the applicant for such permit to file a signed StalCmcm
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7001) 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 five hundred dollars ($500).
❑ I, as owner of the property, or my employees with wapS as their sale compensation,
will do the work- and the structure is not intended or offered forsalc (Sec. 7044, Business
and Professions Cade: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
awn 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
QL 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 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 Contractors
License Law,
❑ I am B & P CA f this ason
Owner Date f !
W RKER'S COMPENSATION DECLARATION
I hereby affrm under penalty, of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insum 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 Workers 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 one hundred dollars (S 100)
or ICs&)
I certify that in the performan of a work r which this permit is issued, 1 shall not
cm ploy any person in any ma nes as o b me subject te- c orke ' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: , after making this Certificate of Ex mpuon, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you most
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that (here is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
L.cnders Address
I certify that 1 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-memiuned 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 U ST N S D WILL COMPLY WITH AL NON -POINT
SOURCE REGUL
Date
—HAZARDOUS MATERIALS DISCLOSUR
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)?
❑Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants ag defined by the Bay Arca Air Quality Management
District? +� /
❑Ycs X70
1 have read the hazardous materials mquirements under Chapter 6.95 of the Califor-
ao,
ctyCadc, Sections 25505, 25533 and 25534.1 understand that if the building
ly ave a tenan4 that it is my responsibility to notify the occupant of the
prior toissuance of a Certificate of ancy
PERMIT NO.
TBD - TO BE DETERMINED 07020097
PERIMIT L55UE DATE
04/20/2007
SANITARY NO. CONTROL NO.
BUILDING PERMIT DWO
BLDG ELECT PLUMS
Job Description
ADDITION:IST FLR 54' STAIRWAY, 2ND
BEDRMS, 2 BATHRMS—REMODEL: DINING,
BATHROOM.
Sq, Ft: Floor Area
36204042'V(�
Issued by:
Re -roofs
Type -of Roof
FLR 580' 2
KITCHEN &
$150000
Required Inspections
Valuation
Occupancy 'Type
Date -Z 6--07
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