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CITY OF CUPERTINO
BUILDING DIVISION PERMI
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BUILDING ADDRESS:
10061 PHAR LAP DR
TBD — TO BE DETERMINED
PERMIT NO.
08010101
OWNER'S NAME: .
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMR'INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Chapter
Job Description
R hereby affirm that I am licensed under provisions of 9 (commencing
with Section 700(n of Division 3 of the Business and Professions Code, and my license is
ADD GARAGE 417 ' , ADD /CONVERT TO
in full force and cffwL
License Caw Lle.N
BEDRM, BATHRM, CLOSET, STUDY, ENTRY 928', PORCH 60'
Date ConARCHITECTS DECLARATION
REMODEL KITCHEN/ SKYLIGHT 2 0 0 ' , REROOF (E) ROOF 30
I understand my plans &hall be used as public recnrdt
Licensed Professional
OWNER -BUILDER DECL.ARA71ON
I hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.5, Business and Professions Code, Any city or county
which requires a permit to construes alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
licensed to the Contracmrs License Law 9
Sq. Ft. Floor Area
Valuation
that he is pursuant provisions of the (Chapter
Section 7000) of Division 3 of the Business and Professions Code) or
$150000
(commencing with
that he is exempt therefrom and the basis for the alleged exemption Any violation of
Number
3 2 618 0 2 6
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five himdmd dollars (5500).
: Cf V
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required fired Ins
win do the wok, and the smmturc is not imended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law dors not apply to an owner of
q p ections
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,).
0 L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractors Li -
ewe Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law,
❑ I am exempt u
DECLARATION
1 hereby &frmrm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Cenifiate of Consent to self-insum for Workers Compen-
satiort, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued -
F1 1 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 am:
Cartier. Policy No.:
CERTIFICATE OF HKEMFnON FROM WORKERS'
COMPENSATION INSURANCE
(This section treed not be completed if the permit is forone hundred dollars MOM
or less)
I certify that In the performance of the work for which this permit is issued I shall not
employ any person in any manner so,}sgnc su�b�'txt to the Workcrs' Compensation
.
Laws of Califonria,-pye�'ijt�-77o��
Applicantj r�17�T/ hlL
NOTICE T'O APPLICANT: If, after making this Certificate of Exemption, you should
became 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
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec, 3097, Civ. Q
Lenders Name
,
Lenders Address
I I certify that I have read this application and state that the above information is
corect. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mmntioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City,
in consequence of the granting of this P=IL
APPLICA ANDS A D WILL COMPLY W[TH AC.L NON -POINT
Issued Date
SOURCE UL 3
tog
^
Re -roofs
Type of Roof
Signature of App rant/Contrtctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building omrpantatom orhandle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Crede, Section 25532(■)7
All roofs shall be inspected prior to any roofing material being installed.
❑Ya �ANo
If a roof.is installed without first obtaining an inspection, I agree to remove
Will time 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?
❑ Yes �[Nu
1 have read the hazardous materials requircmcnts under Chapter 6.95 of the Califor-
nia Health & Safciy Cake, Sections 25505.25533 and 25534.1 understand thatif the building
docs not currently ha ■ mnanL that it is my responsibility to notify the occupant of the
requircme to issuance of a certificate of
Signature of Applicant Date
All roof coverings to be Class'14" or better
Dam
Owner or authorir .sent