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CITE' OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILD N��J91D ESS:
PERMIT NO.
3 ALCAZAR AVE
TBD — TO BE DETERMINED
07060099
OWNER'
7
PHONE:
SANITARY NO. CONTROL NO,
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(IU) of Division 3 of the Businessand Professions Code, and my license is
HOUSE DEMO
in full form and effect.
License Class Lic. s
NEED CONTRACTOR INFO
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public rcenrds
Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Profession Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any strucare
prior to is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed to the of the contractor's Lkense Law (Chaps 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$10000
shat he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
y
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicam to a coil penalty of
not more than five hundred dollars (5500).
3 5 71 9 0 5 8 .
❑ 1, as owner of the property, or my employees with wages as their sok compensation,
Required fired Ins ec[lons
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Profusions Code: The Contractors 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
sale.).
I. as owner of the property, am exclusively contracting with licensed contneras to
construct the project (Seer. 7044, Business and Professions Code:) The Conrxtoes 1.1-
cense Law does not apply to an owner of properly who builds or improves thereon, and ,
who contracts for such projects with a conractor(s) licensed pursuant to the Cmuactors
License Law. c
r
ZLI_arp exempt -der Sec _ B & P C flor 04 maWn
Owe
.
E3VS MPENSAMON DECLARA�IiON-
1 hem affirm under penalty of perjury one of the following declarations
❑ I have and will maintain s Cutiticlte of Consmu m seg-insure for Workers Canpen-
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 lavuance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
'
My Workers Compensation Laurance wrier and Policy number am:
Cartier. Policy No_
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Ibis section need not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person m any manner so as to become subject to the Workers' Coinpensaton
Laws of California Date
Applicant A
NOTICE TO AP I a r making this Certificate of Excut on, y u shauW
become subject orker's Compensation provisions of the Labor Code, you most
„tor/{ire
forthwith compl th such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction larding agency for the performar= of
the work for which this permit is issued (Sec- 3097, Civ. C.)
'
Leader's Name
,
Lenders Address
I certify that 1 have orad this application and state rhes the above information is
correct I agree to comply with all city and county ordinances and state laws relating to
building convection, and hereby authorize representatives of this city to enter upon the
above-mcn6uned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgmcnu, costs and expenses which may in any way accrue againstsaid City
in consequence of the granting of this permL
APPLICANT UNDERSTANDS AND LL COMPLY WITH ALL NON-P INT
Issued by: Date
SOURCE REGULATIONS. /
Re-roofs
Type of Roof
0 0
HAUS MATERIALS DISCLOSURE tic
Signature of A IZonARDO
Will plieant or future building occupant Store or handle hrimdous material
as defined byKthe Cupertino Municipal Code, Chapter 9.14 and the Health and Safety
code,C)Yes �No n2ss32(a)7
C) Yes
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
Will the 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.
Disrict7 —
❑ Yes (}No
I have read the hwm dour materials requirements under Chapter 6.95 of the Califor-
nia Health &Safety Code, Sections 25505,25533 and 25534. 1 understand "if the building
does not currenty have a tenant, tat 11 is my responsibility to notify the occupant of the
requirements wh must mel prior to iss ofa cemificalnofocca
Signature of Applicant Date
p
All roof coverings to be Class "B" or better
zed
O na autho agent