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CITY ®F CUPk�1L"1'lf
BUILDING DIVISION
BUILD2 0
OWNER'
LICENSED CONTRACTOR'S DECLARATION
I hcrcby affirm that I am limnscd�undcr provisions n[ Chaplcr 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in tali Cone and effe � �:'3'�'� � 4
License Clazs S Lic. # _
Date �� o Contractor � � 1J 1 1
I understand
OW NER-BUILDER DECLARATION
r, I hcrcby affirm Thal 1 am exempt Crum the Contracmrs License Law for the
followirfg reason. (Section 7031.5, Business and Professions Code: Any city or county
which' requires a permit to construct, alter, improve, demolish, or repair any sWetum
prior llt iN issuance, also squires the applicant for such permit to file a signed stamment
that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law (Chapter 9
'(commencing with Section 7000) of Division 3 oC the Business and Professions Code) or
Ural hr, is exempt'thcsfrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($500).
❑ I, az owner of the property, or.my employees with wages az their sole compensation,
will do the work, and the struclus is not intended or oftered forsalc (Sec.7044, 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 himselCar Utrough his
own employees, provided that such improvements are not intended or ofiered forsale.IC,
however, the building or improvement is sold within one year of wmpicGon, the owner-
6uilderwill have the burden oC proving that he did not build or improve Cor purpose of
salcJ,
� I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Processions Code:) The Conhacmrs Li-
cense [aw docs not apply to an owner o(propeny who builds or improves theson, and
who contracts far such projects with a eonuaclor(s) licensed pursuant tb the Contractors
License Law.
❑ I am exempt under Sec. , B & P C for this_rcason
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Owner Date
WORKER'S COMPENSATION DECLARATION
]hcrcby affirm under penalty of perjury one of the following declarations:
�1 I have and will maintain a Cer66cale oC Consent loself-insure for Worker's Compen-
Eation, as provided for by Section 3700 of the Labor Code, (or the performance oC the
cork for which this permit is issued.
] [have and will maintain Workers Compensation Insurance, az syuisd 6y Section
3700 of the Labor Code, Car the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
' PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
BUILDING PERMfr INFO
BLDG ELECT PLUMB MECH
- Job Description
ADDITION 138'—EXTEND GARAGE 7' TO THE
'FRONT, EXTEND'
aTHE FAMILY RQOM 7'TO THE GARAGE
(This section need not be completed if the permit is for one hundsd dollars (5100)
or IcssJ
I certify thet in the pertormance of the work for which this permit is issued, I shall not
employ any person to a man s az� to� �66ff��om subject to the Workers' Compensation
Laws'of Califor ' . lcuY[/D�
Applicant ��
NOTICETO] A�T: �,�crmaking this Ccrtificam of Ezcmphon, you should
become subject to the Worker's Compensation provisions of the Lahor Code, yea must
forthwith comply with such provisions or this permit shall be deemed svoked.
CONSTRUCTION LENDING AGENCY
I herby afLrm that there is a conslructinn lending agency Cor the performance of
Ure work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the ahove infortnatiun is
correct. 1 ogre to comply with all city and county ordinances and state laws relating to
building conswction, and hereby authorise representatives of ihiscity to enter upon the
ahove-mentioned property far inspection purposes.
(We) agree to save, indcmni(y and keep harmless the City of Cupertino against
IiahiliUes, judgmenls,costsond expenses which may in any way accme againslsaid City
in consequcncc oC the granting o(Ihis permit.
APPLICANT U STANDS AND W COMPLY ITB ALL NON -POINT
SOURCE RE ONS, � � 2 �/a
'� � � HAZARDOUS MATERIALS DISCLOSURE
WiII the applicant or future building occupantstore orhandlc hazardous material
az`defined by the Cupertino Municipal Code, Chapmr 9.12, and Ute Health and Safety
Code, Section 25532(a)? ,�('/,
❑ Ycs YJ „U
Will the applicant or fuwrcbuilding occupant use cyuipment or dcvirxs which
emit hazardous air contaminants az defined by the Bay Area Air Quality Management
DiStrici?
. ❑Ycs �No
1 have read the hazardous materials rcyuircments under Chapter 6.95 of the Calitor-
nia Health & Safety Cadc, Sections 2551)5, 25533 and 25534. I understand that iCthe building
docs not currcnUy.hav tenant. that it is my r sponsihility to noGCy the orxupant of the
rcyuircmcnts v}AicSr ust brrme�dor to issu tcc of a CcrtiGcatc of acupanc}:
owner
Date
q. Ft. Floor Area
35915025:
Issued by: j�
Re -roofs
Type of Roof
$27000
Required Inspections
�[iCtr7i1
Occupancy Type
Date �-2
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
all new materials for inspection.
Signature of Applicant Date
Al] roof coverings to be Class "B" or better