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CITY OF CUPERTINO
BUILDING DIVISION PERMRM
(CO�Ai tTIl&4CTOR. HTFO TtD�
BUILDING ADDRESS:
T1•..,•'C'HCON
PERMIT NO.
10460 SERRA DR.
03010094
01/16/2003
PHONE:
4 0 8 778 —13 5 0
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
P
with Sectionr 7000) of Division 3 of the BKSiness and Professions Code, and my license is
in full forc�p,A erred. ✓ —I -�
GAS LINE
License C Lie. b' Z•j
Date Co c
ARCHHE 1S LARAT N
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 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 file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area $ 11900tion
(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 ofOccu
ane Type
Occupancy YP
not more than live hundred dollars ($500).
❑ 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
and Professions Code: The Contractors License Law does not apply to an owner of
We iG
property who builds or improves thereon, and who does such work himself or through his
202 — UNDERF
own employees, provided that such improvements are not intended or offered for sale. If,
301 — ROUGH PLUMBING
however, the building or improvement is sold within one year of completion, the owner-
302 — TUB & OR SHOWER
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
502 — FINAL PLUMBING ENERGY
❑ I, as owner of the property, am exclusively contracting with licensed conuactors to
506 — GAS TEST
construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense Law does net apply to an owner of property who builds er improves thereon. and ,
507 — F I NAL PLUMBING
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 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 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 W/orker's C mpensation Insurance Barrie/ry�nd`PoIiCAY number are:
c3 � �
A 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. Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
r
CONSTRUCTION LENDING AGENCY
1 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.)
Lenders Name
Lender's Address
j 1 certify that 1 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
1 above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
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j liabilities, judgments, costs and expenses which may in any way accrue against said City
' in consequence of the granting of this permit.
APPLI ANT
/
___1;* , 1
6
Re -roofs
'
Type of Roof
Sign re Applicant/Contra or Date
HAZARDOUS MATERIALS DISCLOSURE
ill a applicant or future building occupant store or handle hazardous material
as defin by a Cupertino Mui ici o c. Chapter 9.12, and the Health and Safety
Code. Seed 5532(a)?
All roofs shall be inspected to any roofing material being installed.
❑ Yes 41 No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future build' occupant use equipment or devices which
emit hazardous air contaminants as tied by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes o
1 have read the haza us materials requirements under Chapter 6.95 ofthe Califor-
nia Health &Safety Code, Sections 25505.255333ffd 255k4. I understand that if the building
does not current) have a tenant, tit ' y sponsibi to nobf the occupant of the
requiru whi must be mel a iss ce nr a certi t te Oce ey.
Signature of Applicant Date
"°
All roof coverings to be Class "B" or better
Owner or authoragent Date