05010022CITY OF CUPERTINO
BUILDING DIVISION PERMtr',
BUILDING ADDRESS: PERMIT NOO50100 2 2
PERMIT ISSUE DATEOWNER'S NAME:
BUILDING PERMIT IN 0
BLDG ELECT PLUM
ARCHITECT/ENGINEER:
MECH
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~:? g LICENSED CONTRACTOR'S DECLARATION Job Des'crl·ptl·on ~ u t;: I hereby affirm thai I am licensed under provisions of Chapter 9 (commencing ;; ~ g: with Section 7000) of Division 3 of me Businc.~ and ProCessions Code. and my license is
'-::> '" in full force and effI:Jl. ''?'-IB:U \G:. ADD 882 SQ.FT (MS BED/GREAT RM/WORKSHOP)l ~~ License Class 0 Lie. # ~ . \ t"T":' -\~ f-_ S Date ConlraetorNDmM\S U\i\\cU:ts CONTRACTOR: LANDMARK BUILDERS -ARCHITECTS DECLARATION ~ ~:::l I understand my plans shall he used as puhlic recneds FEES ADJUSTED-(03/14/05)~lft5 ~ u. f-Licensed Pnlfcssional ~~j OWNER·BUILDER DECLARATION
I hereby affirm thai I am exempt from the COnlraC10C's License Law for tbe51~ :!; following reason. (Section 7031 ..5. Business and Profcs-'iions Code: Any city or county;:~~ which requires a pcnnit to consLrucl, aller, improve, demolisb, or repair any SlruClure><"" U.;,u-cn prior to il.s issuance, also requires thc applicant for such pcnnit La file a signed Slatement f--------:;::;--;::;:-----;:;;---.--:-------,----------;--;-;--:-:----t-----f-Z> thai he is licensed pursuant 10 Ihe provisions of Ihe Conlraetor's Liccnse Law (Chapler 9 Sq. Ft. Floor Area Valuationix~ (commencing with Scction 7(00) of Division :\ of the Business and Profcssions Code) or
!e~-Lhal he is exempt therefrom and the basis for lhe alleged exempli on. Any violaLion of I -;-:;:;:;:-;-~-__;_-_-------+-------__;~--',;L:;U;L;~i.J,!.J.!\-------
Section 7031.5 by any applicant for a pennil subjects thc applieanlto a civil penally of r APN Number
nOI more than five hundred dollars (S500).
«f-:i
o I, as owner of me property, or my employees wim wages as their sole compensation,
will do the wall<. and thestruelu," is not intended or offered for sale (Sec. 7044, Business 1-------"l'"!~~n7"<"'i..,.,-7\70\------l-----------------+------
and Professions Code: The Conuaetor's License Law docs not apply 10 an owner of Required Inspections
propeny who builds or improves thereon, and who does such work himself or lhrough his
own employees, provided mat 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 me burden of proving that he did not build or improve for purpose of
salc.).
o I, as owner of the propenYl am exclusively contracting with licensed contractors to
construe' the project (Sec. 7044, Business and Professions Code:) The ConuaelOr's Li·
cense Law does not apply to an owner of propeny who builds or improves thereon, and .
who conU'acts for such projects with a contraclor(s) licensed pursuant to lhe Contractor's
License Law. o I am exempt under Sec. , B & PC for this reason
Owner ----;W'"'O"'R"'K;;-ER='S;;-;;C;;::O.,-M;;P:;:E"'N;;::S-;AT:;;I;;:O"'N;-;D"'E;::C;::LA;-;-;;:RA~~~Nc------
1 hereby affinn under penalty of pelju!)' one of the following declarations:
o I hlilo"e and will mainlain a Certificate of Consent to self-insure for Worker's Compen
sation, as provided for hy Section 3700 of the Labor Code, for the perfonnance of the
work for which this pennit is issued.
o 1 have and will maintain Worker's Compensation Insurance. as required by Section
3700 of the Labor Code, for lhe perfonnance of the work for which this pennil is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Canier: NI:c... ~ Policy No.: 1'iC\fA2'Uli
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seclion necd nOl he completed ifthe pennil is for one hundred doll.,. (SI()())
or less.)
I cenify L~at in the perfonnance of the work for which this permit is issued. I shall not
employ an)· person in any manner so as 10 become subject to the Workers' CompensationLaws of California. Date _
Applicanl~__. ---, _
NOTICE TO APPLICANT: If. afLcr making this Cenifieale of Exemplion. you should
become subject to the Worker's Compensalion provisions of Lhe Lahor Code, you must
fonhwilh comply wiLh such provisions or this pennil shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I herehy affirm Lhat there is a construction lending agency for the perfonnance of
the work for which this penniL is issued (Sec. 3097, Civ. C.)Lender's Name _
Lender's Address _
I eenify Lhat I have read Lhis application and slate Lhallhe above information is
correct. I agree to comply wiLh all city and county ordinances and stale laws relating to
building construction, and hereby authori7.e representatives of this city to enler upon the
ahove-mentioned property for inspection purposes. ~
(We) agree 10 save, indemnify and keep harmless thc Cily of Cupenino against J
te
HAZARDOUS MATE IALS DISCLOSURE Type of Roof !
Will the applicant or fUlure building occupant store or handle hal.a.rdous malCrial
as defined by the Cupenino Municipal Code, Chapler 9.12, and the Health and SafelY
I
Code, Scclion 25532(a)7 ~o All roofs shall be inspected prior to any roofing material being installed. IDYes 'f-""
If a roof is installed without first obtaining an inspection, I agree to remov~WiIIlhc applicanl or fUlure building occupant usc equipment or devices which
emil ha7.ardous air contaminants as defined hy the Bay Area Air Quality Management all new materials for inspection. I
District?
DYes fJJ No I
Signature of Applicant Date
All roof coverings to be Class "B" or better I