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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUTL.DING ADDRESS:
PERMIT NO.
OWNS ' A E:
-
SAN074Y 1_138 / 2 p p 7 CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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LICENSED CONTRACTORS DECLARATION
-ENTRY _9P;li,P_:_P r
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
35 SQ . FT . , RE -ROOF,
with Section 7000) of Divialon 3 of the Business and ProfessionsCodc, and my license is
in full force and affect
License Class Lie. A
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
.
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to concoct alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
diet he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cod ,l or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy e
P y TYP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and The structure isnot intended oroffered for sale (Sec.7044.Business
and Professions Code: The Conuaetor's License Law does not apply to an owner of
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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
rsale
I, as owner of the property, am exclusively contracting with licensed contractors to
wct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li-
cense Law does act apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a conu=or(s) licensed pursuant to the Contractors
License Law.
❑ lam exempt under m , B & P C for this reason
Owner�sGs D
WORKER'S COMPENSATION DECLARATIOIT
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's 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 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 Polity number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhis section need not be completed Tribe permit is foronc hundred dollars ($100)
or less.)
1 cenifv that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as me subject to the Workers' Compensation
Laws of California. Date% r� -
Applicant
NOTICE TO APPLICANT: If, after maldng this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
,
Lenders Address
I certify that I have read this application and state that the above information Is
correct 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
ahove-mentioned 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 permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGU S.
Re -roofs
Type of Roof
Signature of Applicam/Contraetor
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ectvpanl store or handle hazardous materiel
as defined by the CupeNno Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? `
❑Yes Nn
All roofs shall be inspected prior to any roofing material being installed.
�,1j�❑
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant 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
lit read the haaardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cadc, Sccdons 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
'
requirements which must be met prior to issuance of a Certificate of OcL/7 .
Signature of Applicant ieant Date
All roof coverings to be Class "B" or better
Owner or autho agent Da