07030231UY OF CUPERTINO y��qy
BUILDING DIVISION PERNUT
PERMIT NO.
ANFORD PL TBD — TO BE DETERMINED 07030231
ARCHITECTIENGINEER:
o a LICENSED CONTRACTOR'S DECLARATION
w p 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
i Z¢ s with Section 70W) of Division 3 orlhc Business and Professions Code, and my license is
= w in full force and effect.
? License Class Lic. #
F, a Date Contractor
ARCHITECTS DECLARATION
WU I understand my plans shall be used as public records'
cE
� rn Licensed Professional
OWNER -BUILDER DECLARATION
1 ¢ g 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
20 0 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 structure
Z y prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contractor's license Law (Chapter 9
Fm (commencing with Section 7000) of Division 3 of the Businessand Professinns 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 (S5o(T).
❑ I, 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 does not apply to an owner of
property who builds or improves thereon, and who does such work himself or througb 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
�sal -),
I, as owner of the property, am exclusively contracting with licensed contractors to
constmct the project Sec. 7044, Business and Professions Code;) The Conuacmr's Li-
cense Law dory nol pply to an owner of property who builds or improves thereon, and
who contracts for su h projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt un r Sec , B & P C fo4this mason
Owner _- Date
I herebyl under penalty of peponc' to following declarations:
❑ 1 have and wil aintain a Ccrtifiotc oMoment to self -insure for Worker's Compen-
sation, as provide for by Section 3700 of the Labor Code, for the performance of the
work for which this permitis issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Worker's Corn pensadon Insurance carrier and Policy number art::
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in aj�y manner so as to become subject to the Workers' Compensation
Laws of California. nD I{
, y u sho d
become subject to a orker's Compensa 'on isrons of the Labor Code, you must
.J 0 forthwith comply w such pvisions or th s crm 'I,I be deemed revoked.
Z Uj CONSTRUCTION LENDING AGENCY
I hereby a(rirm that there is a construction lending agency for the performance of
the work fur which this' permit is issued (Sec. 3097, Civ. C.)
Q Lendcr's Name
ram- z Vnder's Address
U Q I certify that 1 have read this application and state that the above information is
l� """ correct. I agree to comply with all city and county ordinances and state laws relating to
Q U building construction, and hereby authorize representatives of this city to enter upon the
shove -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
H r/I liabilities, judgments, sts and expenses which may in anyway accrue against said City
U Z in consequence of the ranting of this permit
APPLICANT UNDE STANDS AND WILL COMP WITH ALL NO -POINT
SOURCE REGULATI
of Ap 'cangContracior /Date t,
Will the appli t or future building occup&dstore or handle hazardous material
as defined by the Curidnino M _ipal Code. Chapter 9.12. and die Health and Safety
Code, Sccdon 25532( ?
❑Yes o
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 ❑4
I hzvc mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc Sccdons 25505.25533 and 25534.1 understand that if the building
does not currcndy have