031000800
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CITY OF CUPERTINO
BUILDING DIVISION PERM]
BUILDING ADDRESS:
PERMIT NO.
03100080
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION,
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in fulland effect.
LicenseClassLtc N
TI --BEAUTY
SALON (7 5 8 S Q . FT . )
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall be 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
Sq. Ft. Floor
Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(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
37507045.00
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars ($500).
❑ I, as owner of the property, or my employers with wages as their sole compensation,
101 -
FOUND� d Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7D44. Business
and Professions Code: The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
102 -
PIERS
own employees, provided that such improvements are not intended or offered for sale, If,
10 3 -
OF ER
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 -
RE BAR
.ale')'
105 -
ANCHOR BOLTS
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.
106 —
SEWER & WATER
cense Law does not apply to an owner of property who builds or improves thereon, and ,
2 0 2 —
UNDERFLOOR PLUMBING
who contracts for such projects with a contraclor(s) licensed pursuant to the Contractor's
License Law.
203 —
UNDERFLOOR MECHANICAL
❑ 1 am exerttp un 6r Se , B & P C for this re on
left p�
204 —
UNDERFLOOR FRAME
o / ate
WORK l2'S COMPENSATION" ATION
205 —
UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one of the following declarations:
301 —
ROUGH PLUMBING
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
302 —
TUB & OR SHOWER
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
303 —
ROUGH ME CHAN I CAL
work for which this permit is issued.
304 —
ROUGH ELECTRICAL
❑ 1 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
Carrier. Policy No,:
CERTIFICATE OF—EXEMPTION FROM WORKERS'
307 —
INSULATION '
COMPENSATION INSURANCE
308 -
SHEETROCK '
(chis section need not be completed if the permit is for one hundred dollars ($ 100)
—
EXTERIOR LATH -
or less.)
.309
310 —
INTERIOR LATH
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 Workers' Compensation
311 —
SCRATCH COAT
Laws of California. Date
Applicant
313 —
501 —
ROOF NAIL
FINAL ELECTRICAL ENERGY
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.
502 —
FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY
503 -
F I NAL MECHANICAL ENERGY
1 hereby affirm that there is a construction lending agency forthe performance of
504 -
FINAL BUILDING ENERGY
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
505 —
506 —
FINAL ELECTRICAL
GAS TEST
Lenders Address
I 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
507 -
FINAL PLUMBING
building construction, and hereby authorize representatives of this city to enter upon the
FIN MEC CAL
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
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F I
liabilities, judgments, costs and expenses which may in any way accrue against said City
consequence of the granting of this permit.
5
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APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: 5
C WORKS Date
SOURCE E UL o D l�r(7q R
Re -roofs
Type of Roof
Sighature of Applica l/Contractor ale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal.Codc, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
E3 Yes ONO
All roofs shall be inspected prior to any roofing material being installed.
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.
Districl? pr
❑ Yes ;n] No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
alifor-niaHoalth&SafetyCode,
nia Health & Safety Code,Sections 25505,25533 and 25534. 1 understand that if the building
docs not currently ha e a tcnan4 at itis y responsibility to notify the occupant of the
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requiremen
,�% wlo� a3
Signature of Applicant
Date �-
All roof coverings to be Class "B" or better
Ow or aulhorizad ager Datc