03030087CITY OF CUPERTINO
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'!,'r�W WOR I�
BUILDING DIVISION ]P]E;]� �'
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BUILDING ADDRESS:
10439 AUU ARRnR Aug
PERMIT N0.
OWNER'S NAME:
PERMIT JS5 300
PHONE:
SANITARY N L NO.
ARCHLTECrfENGINEER:
-
BUILDING PERMIT mo
BLDG � PLUMBMECH
F-7LICENSED
CONTRACTOR'S DECLARATION
lob Descri t10n
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
p
with Section 70(10) or Division 3 of the B\ri'` and Professions Code, and my license Is
in full LICenseC dere LIQ �'� /
KITCHEN REMODEL/LIGHT
UPGRADE
15 GO tractor
WINDOW REPLACEMENT
L)ccn3e� n
OW NER-BUILDER DECLARATION
I befi affirm that I am exempt from the Conrradors 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 Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cock) or
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70313 by arry applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500)
P Y
❑ 1, as owner or the property, or my employees with wages as their sole compensation,
32628025.
0 0
will do the work and the structure is not Intended oroRemdfor sale (Sec.70",Business
Professions Code: The Contractors License Law dors to owner
Required Inspections
e Q p
and not apply an or
property who builds or improves thereon, and who does such work himselror through his
101
- FOUNDATION
own employees, provided that such Improvements are not Intended or offered for sale, If,
10 2
- PIERS
however, the building or Improvement is sold within one year orcompietion. the owner•
builder will have the burden or proving that he did not build or Improve for purpose or
103
- OF E R
sale.).
104
- REBAR
❑ I, as owner or the properly, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's Li-
105
- ANCHOR BOLTS
cense Law does not apply to an owner of property who builds or improves thereon, and .
Who contracts for such projects with a contmctor(s) licensed pursuant to the Contractors
10 6
- SEWER & WATER
License Law.
❑ I am exempt
pt under See B & P C for this mason
202
- UNDERFLOOR PLUMBING
203
- UNDERFLOOR MECHANICAL
Owner Date
WORKER'S COMPENSATION DECLARATION
204
- UNDERFLOOR FRAME
I hereby affirm under penalty of perjury one of the following declarations:
205
— UNDERFLOOR INSULATION
❑ I have and will maintain a Certificate of ConWM to self -insure roe Worker'acompen-
301
— ROUGH PLUMBING
cation, as provided for by Section 3700 or the Labor Code, ror the performance or the
302
- TUB & OR SHOWER
work for which this permit is issued
I have and will maintain Worker's Compensation Insurance, as required by Section
303
- ROUGH ME CHAN I CAL
3700 or the Labor Code, for the performance of the work for which this permit is issued.
304
— ROUGH ELECTRICAL
My Workers Compensadon Insu nce carni and Policy number are:
Cir
305
- FRAME
V CE IFICATE0 FXEMi nONFR0WORKERS
306
- HOLDOWNS
COMPENSATION INSURANCE
(This th tdssectionneednotbecompletedirlsforonehundreddollarsIS100)
307
- INSULATION
or less.)
308
- SHEETROCK
I certify that In the perfonins.we of the work for which this permit is issued. I shall trot
309
— EXTn I OR LATH
employ any person in any manner so as to become subject to the Workers! Compensation
310
— INTERIOR LATH
Laws or California. Date
Applicant
311
- SCRATCH COAT
NGnCE TO APPLICANT: If, after making this Certificate of Exemption, you should
313
- ROOF NAIL
become subject to the workers Compensation provisions or the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed evoked
5 O 1
- FINAL ELECTRICAL ENERGY
" CONSTRUCTION LENDING AGENCY
502
- F I NAL PLUMBING ENERGY
I herby affirm that there is a convection lending agency for the performance of
' the work for which this permit is issued (Sec. 3097, Civ. C.)
503
- FINAL MECHANICAL ENERGY
Lenders Name
504
- F I NAL BUILDING ENERGY
r Lender's Address
I cenify that I have read this application and state that the above information is
505
- FINAL ELECTRICAL
" correct. I agree to comply with all city and county ordinances and state laws relating to
506
- GAS TEST
building construction, and hereby authorl2m mrimsentatives of this city to cntef upon the
N PLUMB Gabove-mentioned
properly for inspection purposes(We)
agree m save, indemnify and keep "j ity of Cupertino against
0 8
L
11 liabilities, judgments, costs an way accrue against said City5in
consequence or the gra APPLICANT U i ALL NON -POINT
Issued by: 5SOURCERe-roofs
6NAL
514
Type of Roof
PUBLIC WORKS
tea
• US MATERIALS DISCLOSURE
Will thescant or future building occupant store or handle havArdousMatcrial
as defined rhe Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
tion 25532(a)?. I
All roofs shall be inspected prior to any roofing material being installed.
01Code•
Yu N o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or tutu building occupant use cyuipment or devices which
cmil hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials
for inspection.
District?
❑ Yes o
1 have read the ha 1 oq nde apter 5 of the Califon.
nia Health & Safet d that irthe building
docs not cu fy the occupant of the
r�ai teof Oc
Signature of Applicant Date
3;rl.
All roof coverings to be Class "B" or better
roratr g
a