09030049CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
CONTIl.OL NO.
ARCHITECTIENGlNEER: BUILDING PERMIT INFO
BLDG ELEcr PLUMB MECH
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701-1500
=,1.1__61 =L1__61 =L1_---!I=dl_• I LICENSED CONTIl.AcroR'S DECLARATION ~ ~ t: I hereby affirm that I am licensed under provisions 01 Chapter 9 (commcncing Job Description
z U with Section 7000) 01 Division 3 01 the Business and ProlessionsCode,and my license is ~~~ ti::~I~o~~~nderrecL~ Lie. II ,'ll O~~ REVISE,INCORP STRUCTURAL PLANS FOR FLOOR BOXES,
~~ffi Date ;),/;2., b';;" Contractor ~ C...l+r¥<-fun STRUCTURAL WALLS, LIGHTING & ELECTRICAL. NO
-... ARcHmcrs DECLARATION ~ ~... I understand my plans shall he used as public records CHANGE S ~&~
t .. 1Licensed Prolessional
OWNER·BUILDER DECLARATION
~~3 I herehy .lTirm that I am exempt lrum the Conlractor's License Law lor the~~:ll.00 lollowing reason. (Section 7031.5, Business and Prolessions Code: Any city or county ~~!l:which requires a pcnnit to conSlrUCI.. alter. impm\'C. demolish. or repair any sltUcturc.,-",prior to ilS issuance, also ""lui"" the applicant lor such permit 10 file a signed statement 1--------;::---;:;:-y::;;;-:--7-:--~~~~~II~~-----__::_:_:_-:__--------_z> lhat he is licensed pursuanllo the provisions 01 the ConlraCtor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation~:;:~ (commencing with Section 7000) of Division 301 lhc Business and Prolessions Code) or
f~-that he is e.empt therelrom and the basis lor the alleged exemption. Any violation 01 0~bgl~~~.~~ape~~~lhc~~toa~pe-~~------~M~~N~N~u=m~b=e=r~------~-~~~-~O~C-c-u-p-an--c-y~T~y-p-e-----
:II I-:iii
not more than five hundred dollars ($500).
o I, as owner 01 the property, or my employees with wages as their sole compensation, L3_1_6_0_2_1_0_9_._0_5 -~:____:_.L-------------------
will do the wor!<. and the structure is not inlended or otTered lor sale (Sec. 7044, Business I
and Prolessions Code: The ConllaCtor's License Law does IIOt apply to an owner 01 Required Inspections
propeny who builda or improves thereon, and who does such work himsell or through hi.
own employees, provided tha, such improvements arc not inlended or otTered lor sal.. 11,
however. the building or improvement is sold within one year 01 completion, rhe owner
boilder will have the burden 01 proving that he did not build or improve lor purpose 01
sale.).
o I, as owner 01 the propeny. am exclusively conlraCting with licensed conlraCtors to
construct the project (Sec. 7044, Business and Prolessions Code:) The Contractor's Li·
cense Law does not apply to an owner 01 property who builds or improves thereon. and .
who contracts (or such projects with a canlJ'aelor(s) licensed pursuanl to the Contractor's
License Law. o I am e.empt under Sec. , B & PC lor this reason
Owner -:-:-:===-==-======== Dale ...,-_
WORKER'S COMPENSATION DECLARATION
I hereby affirm onder penally 01 perjury one 01 the lollowing declarations:
o I h."" and will maintain a Cenificale 01 Consent to sell·insure lor Worker's Compen·
sation, as provided lor by Section 3700 01 the Labor Code, lor the performance 01 the
work (or which this permit is issued.
IJl["[ have and will maintain Worker's Compensation Insurance, as ""Iuired by Section
3700 01 the Labor Code, lor the performance 01 the won: lor which this permit is issued.
My Worker's Comll"~on Insurance cprrier and Policy number arc:
Carrier: Rep\! bl,e, J"1dp..", ':,policy No.: ~ £';),0'19-0 Sl
CERTIFICATE OF EXEMmON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed il the permit is lor one hundred dollars ($ 1(0)
or ICSI.)
I cenily that in the perlormance 01 the work lor which this permit is issued. I shall not
employ an)" person in any manner so as to become subjcctlO the Workers' CompensationLaws olCalilornia. Date _
Applicant __~-------------------
NOTICE TO APPUCANT: II, aru:r making this Certificate 01 Exemplion, you should
become subject 10 Ihe Wor1<cr's Compensation provisions 01 the Labor Code, you must
lorthwith comply with such provisions or this permilshall be dcemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consuuction lending agency ror the performa..." 01
the work lor which this permit is issued (Sec. 3097. Clv. C.)
Lender's Name ------------Lendcr'sAddleSS _
I certily that I have read this applicalion and stale that lhc abuve informalion is
cameL I agree to comply with all cily and county ordinances and Slate laws relating La
building consuuelion. and hereby authori7.e n:presentalivcs of this chy to enter upon the
ahove·mentioned property lor inspection purposes.
(We) agree 10 "ve. indemnily and keep harmless the City 01 Cupenino against
liabilities, judgments. coslS and expenses which may in any way accrue againsl said City
in consequence or the graming or this permit.
APPLICANT UNDERSTA AND WILL COMPLY WITH ALL NON·POINT Issued by:
Re-roofs /2---
Type of Roof
WilIlhc applicant or luture building occupant store or handle hu.anlous material
as defined by the Cupertino Monicipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)1
All roofs shall be inspected prior to any roofing material being installed.DYes !'){No
If a roof is installed without first obtaining an inspection, I agree to removeWill lhc applicant or future building occupant usc equipment or devices whieh
emil ha7.ardOUS air conlaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
DisLricl?
DYes ~o
I have read the hv.ardous malerials requiremenlS under Chapter 6.95 01 the Calilor·
nia Health & Safely Code.Sections 25.505,25533 and 25534. I uodcrstand thai ifthe building
docs not Iy have a tenanL thaI it is my responsibility to notily the occupant 01 the
require cots w ich m el prior to issuance or a Certificate of Occupan . Signature of Applicant Date
All roof coverings to be Class ':4" or better
pplicantiContractor
HAZARDOUS MATERIALS DISCLOSURE
SOURCER I'( .
Owner