02030201-DPCITY OF CUPEKI'INO
BUILDING DIVISION PET
PHONE:
ARCHITECTIENGINEER:
LICENSED CONTRACTOR'S DECLARATION
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
in full force and effect.
License Class Lic. #
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 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 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
(commencing with Section 7000) 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 rive hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as thew sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors 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 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.).
❑ I, 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 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 Comracmrs
License Law.
❑ I am exempt under Sec. , B & P C for this reason
Owner
Date _
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury 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.
❑ 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:
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 less.)
I 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
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's 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
Lender's Address
1 certify that I 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-mentioned 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 UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of ApplicanUComractor Date
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 hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
El Yes r7 No
1 have read the hazardousmaterialsrequirements under Chaptcr6.95 of the Califor-
nia Health &Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Owner or authorized agent
Date
CONTRACM INFOR tT ONs
YLOR WOODROW
#10120 IMPERIAL AVE.
PERMIT NO 2110 0 5 8
APPLICAri1xis// I�l ' 2 0 0 2
SANITARY NO. V ' CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
REVISION - RE TA iM RUc*A`ft, S
IN HOUSE USE ONLY, NO NEW PERMIT ISSUED
ORIG. #02030201
Sq. Ft. Floor Area
Occupancy Type
1 V V1Y LS-� 1 V�Y
102 - PIERS equlred Inspections
103
- UFER
104
- REBAR
105
- ANCHOR BOLTS
106
- SEWER & WATER
202
- UNDERFLOOR PLUMBING
203
- UNDERFLOOR MECHANICAL
204
- UNDERFLOOR FRAME
205
- UNDERFLOOR INSULATION
301
- ROUGH PLUMBING
302
- TUB & OR SHOWER
303
- ROUGH MECHANICAL
304
- ROUGH ELECTRICAL
305
- FRAME
306
- HOLDOWNS
307
- INSULATION
308
- SHEETROCK
309
- EXTERIOR LATH
310
- INTERIOR LATH
311
- SCRATCH COAT
313
- ROOF NAIL
501
- FINAL ELECTRICAL ENERGY
502
- FINAL PLUMBING ENERGY
503
- FINAL MECHANICAL ENERGY
504
- FINAL BUILDING ENERGY
505
- FINAL ELECTRICAL
506
- GAS TEST
507
- FINAL PLUMBING
MECHANICAL
�FINAL
09
FIN E
5 1�
G
Re -roofs 6 0 3 - CR'6OF BATTENS
Type of BW4 - ROOF IN -PROGRESS
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