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CITY OF CUPERTINO
BUILDING DIVISION PERMIT r,,,r
C+dNTI�ACTOYZ INFQRMATIQ,,�r ;
BUILDING ADDRESS:
.
PERMIT N0205
CQTTQNWQQT� PR
03090237
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby 1 licensed Chapter 9
Job Description
affirm that am under provisions of (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force
License Class d effect. Lic. q
ADD 48 SQ . FT . /KITCHEN REMODEL
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall tic used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I 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 file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
3 6 17 O 3
APN Number
an
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
. ill do the work, and the structure is not intended or offered for sale (See, 7044, Business
101 -
FOUNDN�AgIid Inspections
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who docs such work himself or through his
102 -
PIERS
own employees, provided that such improvements are not intended or offered for sale. If,
103
— LTFER
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
104 -
REBAR
sale.).
j�.(.,l(
105
- ANCHOR BOLTS
1, as owner of the property, am exclusively contracting with licensed contractors to
tonslruct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
106 —
SEWER & WATER
cense Law docs not apply to an owner of property who builds or improves [hereon, and
202 -
UNDERFLOOR PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License203
- UNDERFLOOR MECHANICAL
am
COMPENSATION DECLARyVON
205
- UNDERFLOOR INSULATION
1 hereby affirm under penally of perjury one of the following declarations:
301
— ROUGH PLUMBING
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
302
— TUB & OR SHOWER
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303
- ROUGH MECHANICAL
work for which this permit is issued.
304
- ROUGH ELECTRICAL
❑ I 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.
3 05
— FRAME
My Worker's Compensation Insurance carrier and Policy number are:
306
— HOLDOWNS
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
307
— INSULATION
COMPENSATION INSURANCE
308
- SHEETROCK
(This section need not he completed ifthe permit is for one hundred dollars (S100)
309
- EXTERIOR LATH
or less.)
310
- INTERIOR LATH
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 become subject to the Workers' Compensation
311
- SCRATCH COAT
Applicant of California. Date
A ppl
313
501
- ROOF NAIL
- FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT: 1!, alter making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the tabor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
502
- F I NAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503
- FINAL MECHANICAL ENERGY
1 hereby affirm that there is a construction lending agency for the performance of
504
- FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
505
506
507
- FINAL ELECTRICAL
- GAS TEST
- FINAL PLUMBING
Lender's Address
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
building construction, and hereby authorize representatives of (his city to enter upon the
above-mentioned property for inspection purposes.
FIN MECH CAL
(We) agree to save, indemnify and keep harmless the City of Cupertino against
C WORKS Date
Re -roofs
Type of Roof
wrc o p Co r 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
n 25532(a)?
Code,[_]Yes
All roofs shall be
inspected prior to any roofing material being installed.
[_]Yes �'}Jo
❑
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?
E] Yes [KNo
d the hazardous materials requirements under Chapter 6.95 of the Cal ifor-
taHeal[h&Safet ode, Sections 25505,25533 and 25534.1understandthatilthe building
)ale