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03090228 (3)700 O mU �ZW d, U. F OQ �}a �0C < opo ff U^v, -za �7C 0 Z C � V LLi � CL G UC � F >4 G UGo CITY OF CUPERTINO BUILDING DIVISION PERK I%oo �;TC)R4 BUILDING ADDRESS: 21140 CANYON DAY WAY LANDSYSTEMS LANDSCAPE PERMIT N003 0 90228 OWNER'S NAME: 3113 MIDDLEFIELD RD PERMIT ISSUE DATE VRIOSTE2003 PHONE: (650)851-2793 SANITARY NO. CONTROL N0. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 LICENSED CONTRACTOR'S DECLARATION I hereby 9 Job Description p affirm that 1 am licensed under provisions of Chapter (commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect - �--� "? f 7 `'��� Y3 ARBOR RETAIN WALL/LANDSCAPE License Cl s Lica , Dq 2 ✓ z Cuntractgr �"' - •h ARCHITECCS��i21,ARATION I understand my plans shall be used as public records Licensed Professional OWNER -BUILDER DECLARATION I hereby affirm that 1 am exempt from the Contractors 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 $i 2ono prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Professions Code) or 34260001.00 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). ❑ 1, as owner of the property, or my employees with wages as their sole compensation, Required Inspections will do the work, and the structure is not intended or offered forsale(Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of Q p property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements are not intended or offered for sale. If, however, the building or improvement is sold within one year of completion, the owner - builder will have the burden of proving that he did not build or improve for purpose of sale.). ❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law, ❑ 1 am exempt under Sec. , B & P C for this reason Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Com Pen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number are: C1 .) i�"—T Policy No.: G✓C- %Z3 '—Z5 % — yT CERTIFICATE OF EXEMPTION E$W+1 WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (sI(x)) or less.) 1 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 hecomc 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 Worker's Compensation provisions of the Labor Code, you must ' forthwith comply with such provisions or this permit shall be deemed revoked. I CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of i the work for which this permit is issued (Sec. 3097, Civ, C.) Lender's Name _ -- Lender's Address i I 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 •�` t building construction, and hereby authorize representatives of this city to enter upon the ahove-mentioned property for inspection purposes. 1 (We) agree to save, indemnify and keep harmless the City of Cupertino against .1 jliabilities, judgments, costs and expenses which may in any way accrue against said City C( in consequence of the granting of this permit., ' APPLIC kT47r UNDERSTAN ,f ND WILL COMPLY WITH ALL NON -POINT SOU •E' EGU,jfATIONS,AN i Issued by: Date ate HAZARDOUS MATERIALS DISCLOSURE of Will the applicant tar 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 shall be inspected to any roofing material being installed. C] Yes [J No roofs prior 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? C] Yes I have read the hazardous in alcrials requirements under Chapter 6.95 of the Califor- nia Health &;Safety Code, Sections 25505, 25533 and 25534.1 understand that if the budding does npl'cumently have a tenant, that it is my responsibility to notify the occupant of the :/ is which mint ;me nor to issuance of a Certifu:ate of Ocekpanc Signature of Applicant Date '�� �. ' All roof coverings to be Class "B" or better Owno or authorized agent Date