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CITY OF CUPERTINO
BUILDING DIVISION PER_._r
CQNTR TU �ilE JG4 _ Alli
BuIL1)I0agggEs!CRESTON DR.
PERMITN10210 0 0 5 8
GWS
APPLICATIl"-9-2002
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby that I am licensed under Chapter 9 (commencing
'
Job Description
affirm provisions of
DEMO
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Class Lic. N
Date Contractor
ARCHITECTS DECLARATION
`
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
$8500
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
Valuation
(commencing with Section 7000) of1Division 3 of the Business and Professions Code) or
he is therefrom and the. basis for the Any
'
'
that exempt alleged exemption. violation of
Section 7031.5 by any applicant for it permit subjects the applicant to a civil penalty of
A
Occupancy Type
not more than five hundred dollars ($500).
❑ I, 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
Required Inspections
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 conractor(s) licensed pursuant to the Contractor's
License Law.
C3,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:
❑ 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.
❑ t 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 Workers Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($100)
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 become subject to the Workcrs' 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.
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.)
Lender's Name
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 conswction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabililies,judgmenls, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
SignalureofApplicantlConractor Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
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.
Cl Yes C] No
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?
Cl Yes C1 No
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 ifthe building
docs not currently have a tenant. that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance ora certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Date
Owner or authorized agent