08060003TTY OF CUPERTINO
t;U(LDIIYG DIVISION PERMIT
x c les
BUILi�I 1pDRESS: PERMIT NO.
1(#5 PENINSULAR AVE TBD - TO BE DETERMINED 08060003
06/27/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHr EC 1ENGINEER: BUILDING PERMIT INFO
ADD BLDG EI_FL'r of MAU
O o LICENSED CONTRACTOR'S DECLARATION
Am I hereby affirm that I am Ykensed under provisions of Chapter 9 (commencing
Z with Section 70DD) of Division 3 of the Business and Professions Code, and my license is
y in full force and effete
AK License Class Lic. i
t In Date Contractor
ARCHITECTS DECLARATION
i
2-.C, 1 understand my plans shall be used as public records
yU
O y Licensed Professional
y g OWNER -BUILDER DECLARATION
1 < f 1 hamby affirm that 1 am exempt from the ConuacuWs License Law for the
: m oe� following mason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
Z } prior to its issuance, also requires the applicant for such permit to file a signed statement
? _ that he is licensed pursuant to the provisions of the Contractors 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
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ L as owner of the property, or my employees with wages as their sole compensation.
will do the work and the structure is not intended or offered for We (Sec. 7044, Business
and Professions Code. The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does sucb work himself or through his
own employees, provided that such improvements arc not intended or offered for ala If,
however, the building or improvement is sold within one year of completion, the owmer-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
y� L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's U.
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a eonttactnr(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt B& P C for this n
Owner !/ / Due 6
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 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
My Worker's Compensation Insurance carrier and Policy number air.
Carrier. Policy No -
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is foram hundred dollars (5100)
or las&)
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 as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workees Compensation provisions of the Labor Coda you must
� Z forthwith comply with such provisions or this peaoh shalt be deemed revoked.
OCONSTRUCTION LENDING AGENCY
F. 4 1 hereby affirm that that is a concoction lending agency for the performance of
R: �: the work for which this permit is issued (Sec. 3097, Civ. C)
QLender's Name
] Z Lender's Address
U 0 1 certify that 1 have read this application and state that the above information is
IL F correct. 1 agree to comply with all city and county ordinances and state Imo relating to
0V building construction. and hemby authorize representatives of this city to enter upon Use
a above-mendoned property for inspection purposes.
(We.) agree to ave, indcmoify and keep harmless the City of Cupertino against
►F -r f/) liabilities, judgments, costs and expenses which may in any way accrue against said City
U in consequence of rho granting of this permit.
—
6 lj
Signature ekKirplicant/Contractifr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as damned by the Cupertino Mwdcipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as damned by the Bay Area Air Quality Management
District?
C] Yes ?4o —
1 have read -the hvsrdous materials mquimments under Chapter695 of the Califor-
nia Health & Safety Cada Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a ==L. that it is my msp_ovp lily to noufy the occupant or the
requite- aJcatc of Ottvpancy. / ,
Date
Sq. Ft. Floor Area
APN
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Type
Date
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
. All roof coverings to be Class In" or better