05070180CITY OF CUPERTINO �^tt
BUILDING DIVISION PERM
BUILDING ADDRESS: PERMIT NO.
19066 05070180
OWNER'S NAME: PERMIT ISSUE DATE
01/06/2006
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Z O p LICENSED CONTRACTOR'S DECLARATION
U 1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
Z with Section 70W) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
j Z License Class Lic. N
n F„ Date 2F Contractor
A CHITECI'S DECLAR ION
U 1 understand my plans shall be used as public records
4
iLLO y Licensed Professional
y OWNER -BUILDER DECLARATION
a 1 hereby affirm that I am exempt from the Contractor's License Law for the
D O following reason. (Section 7031.5, Business and Professions Code: Any city or county
K which requires a permit to construct, alter, improve, demolish, or repair any structure
a Z } prior kr its issuance, also requires the applicant for such permit to file a signed statement
'E = C that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
sr F- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y 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 ($500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. B & P C for this reason
Owner Dare
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workees Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. A Polity No.:
CFI ATE OF EXEMPTION FROM ORI RS'
COMPENSATION INSURANCE
(This section need rat be completed if the permit is for one hundred dollars ($ 100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workces Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z ►-t CONSTRUCTION LENDING AGENCY
.-
F -r ►-t I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit is issued (Sec. 3097, Civ. C.)
aA L.endcr's Name
z Lender's Address
V Q 1 certify that 1 have read this application and state that the above information is
w H correct. 1 agree to comply with all city and county ordinances and state laws relating re
0 U building construction, and hereby authorize representatives of this city re enter upon the
Uabove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
In liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
'r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REp ULA '
Signaturty ApplicanVContracto ' Dare
HAZARDOUS 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)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
emit bazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & SafctyCodc, Sections 25505,25533 and 25534. 1 understand that ifthc building
does not currently have aCCCt��teenant, that it is my responsibility to notiry the occupant of the
requirements which m� met p ' r k)of a Certificate of Occupancy.
� 4/ 145
Owner nr authoriz cent bate
Job Description
T.I.-NEW KITCHEN EQUIPMENT,
TOILETS/ELECT/MECH UNITS ABOVE ROOF
CONTRACTR: TOM'S CONSTRUCTION
Ft. Floor Area
"a -Z
Required Inspections
�1Issued by:
Re -roofs
Type of Roof
$160000
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