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CITY OF CUPERTINO
BUILDING DIVISION PEWT
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PERMIT NO 210 0 0 9 8
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APPLICATIq?VyB1D4Ty 2 0 0 2
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PHONE:
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed unser provisions of Chapter 9 (commencing
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KITCHEN REMODE" Cd L' 11V h CHANGE
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
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License Class Lic. p
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Date Contractor
ARCHITECT'S DECLARATION
I my shall be used as records
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understand plans public
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
V ��'✓� U VL.J $ 3 O O O O
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit m 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
3*9Bt8FFl&1 A&@
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and thebasis for the alleged exemption. Any violation of
i UAPN NDATi UN 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 (5500).
102
— PIERS
❑ 1, 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
Professions Code: The Contractors License Law does not apply to
8 3
— ,
Required Inspections
and an owner of
104
- REBAR
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,
105
— ANCHOR BOLTS
however, the building or improvement is sold within one year of completion, the owner-
106
— SEWER & WATER
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
202
- UNDERFLOOR PLUMBING
�tI, as owner of the property, am exclusively contracting with licensed contractors to
203
- UNDERFLOOR MECHANICAL
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
204
— UNDERFLOOR FRAME
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
205
- UNDERFLOOR INSULATION
License Law.
❑ I am exem t under Sec. B & P C for this reason
301
- ROUGH PLUMBING
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DECLAR ON
303
- ROUGH MECHANICAL
1 hereby affirm under penalty of perjury one of the following declarations:
304
— ROUGH ELECTRICAL
❑ I 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.
306
— HOLDOWNS
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3 O %
— INSULATION
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
308
— SHEETROCK
Carrier: Policy No.:
309
- EXTERIOR LATH
CERTIFICATECOMPENSATION INSURAO INSURANCE
310
310
— INTERIOR LATH
(This section need not becompletcd if the permit is forone hundred dollars ($100)
311
- SCRATCH COAT
or less.)
313
- ROOF NAIL
1 certify that in the pe ortn cc of the work for which this permit is issued, I shall not
5 01
- FINAL ELECTRICAL ENERGY
employ; person in a oner so as to become subject to the Workers' Compensation
Laws of
NNETO APPLICANT: If, after making this Certificate of Exemption, you should
NEA
c subject to the Worker's Compensation provisions of the Labor Codc, you must
504
_
FINAL BUILDING ENERGY
forthwith comply with such provisions or this permit shall be deemed revoked.
505
- FINAL ELECTRICAL
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
506
- GAS TEST
the work for which this permit is issued (See. 3097, Civ. C.)
507
- FINAL PLUMBING
Lender's Name
508
- FINAL MECHANICAL
Lender's Address
1 certify that I have read this application and state that the above information is
509
- FINAL GRADE
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
5
F I NAL PLANNING
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 saidCiryin
144-F
I C WORKS
consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:
Date (01r�
SOURCE REGULA 0 S.
Re -roofs
Type of Roof
� d/,r�� Ab
Si ore of Applicant/Conu �—Date
q{/ 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)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes Wo
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 Arca Air Quality Management
all new materials
for inspection.
District?
❑Yes 1�0Vu
I have read the hazardous materials requirements under Chapter 6.95 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..,/
Signature Of Applicant Date
=>I-
All roof coverings to be Class "B" or better
Date
r or authorized agent