08120089 CITY OF CUPERTINOr � �;
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS: TBT) RE 0089
7551 K I RW I - t PERMIT vE DATE
OWNER'S NAME:
S CONTROL NO.
.tONE:
BUILDING PERMIT INFO
MECH
ARCHITECTCENGINEER: BLDGELECTPL�UMB (�
u O p LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z i with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADDITION 498 ' STUDY, LIVING RM, BATHRM,& PORCH.
D y in full force and effect
v�Z License Class Lor NO
p
Date
ARCHITECTS DECLARATION
I understand my plans shall be used as public records RE-ROOF . INCLUDES STRUCTURAL.
�nm,U
`a H Licensed Professional
OWNER-BUILDER DECLARATION
ny�
1 hereby affirm that 1 am exempt Cru
the Contractor s License Law for the
a O following reason.(Section 7031.5,Business and Professions Code:Any city or county
$ which requires a permit to construct,alter,improve,dcmolLah,or repair any structure Valuation
prior to its issuance,also requires die applicant for such permit to file a signed statement jq Ft.Floor Area
–z< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Y FZ- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
000
y R E that he is exempt therefrom and the basis for lite alleged exemption.Any violation of t to a civil penalty of APN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applican
not more than rive hundred dollars($500). 35921001 - 00
❑1,as owner of the property.or my employees with wages as their sole compensation, Required Inspections
will do the work and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:Ttte 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
own employees,provided that such improvements are not intended or offered for We.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.).
L as owner oC the property,am exclusively contracting with licensed contractors to
co tract the project(See 7044.Business and Professions Code:)71te Contractor s Li-
cense Law does not apply Wan 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. B&P C for this reason
❑1 am exempt under Sec.
—_� Date
Owner WORK 'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have;d=maintain a Certificate of Consent to self-insum for worker's Compen-
sation,as od 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 Workefs Compensation Insurance,as required by Section
3700 of the Labor Codc,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier. 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 Icss.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to ome subject the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APP after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z 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.)
�7 Q L.emices Name
04
Lender's Address
U C) I certify that I have read this application and state that the above information is
VI H corccL I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
>4 a (we)agree to save,indemnify and keep harmless the City of Cupertino against
E"c� liabilities,judgments,costs and expenses which may in any way accrue against said City
V Zin consequence of the granting of this permit. Date
►•+ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued
Sig
Ol REG TIOf NS_�--•—� _ Re-roof:at of App lican✓Contractor Dare T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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 roof;shall be inspected prior to any roofing material being installed.
C]Yes ❑Ne 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
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Ycs ❑No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nisHealth&Safety Code,Sections 25505,25533 and 25534,1 undersand that if the building
does not currently have a tenant,that it is my responsibility In notify the occupant of the Date
requirements which must be met prior to issuance of a Certificate of Occupancy S ignatul a of Applicant
All roof coverings to be Class"{"or better
Owner or a orized agent Date