07070051CITY OF CUPERTINO
DIVISION P RNM
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BUILDING
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TBD — TO BE DETERMINED
BUILIff EShARRANCA DR
PERMIT NO.
07070051
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SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
REVISION OR I G # 0 7 0 7 0 0 51-NO NEW PERMIT OUST
in full force and t. '�ff
class s 53
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Date v.i
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ARCHITECTStrDE�c%A N
87.14 REC #BS000001915 7/6/7. PUT ON ORIG PERMIT
1 understand my plans shall be used as public records
06050091 IN ERROR.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alTrm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. slur, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
the Contractor's License Law (Chapter 9
Sq. Ft. FIOOr Area
Valuation
that he is licensed pursuant to the provisions of
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(commencing with Section 70DD) of Division 3 of the Business and Professions Code) or
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that he is exempt therefrom and the basis for the alleged exemption. Any violation of
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3 2 6 010 07
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ( OML
:
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and thestructurc is not intended or offered foTsale (Sec. 7G44, Business
and Professions Cow The Contractor's License Law does not apply to an owner of
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Property who builds or improves thereon, and who does such wort 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 contractors to
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construct the project (Sec. 7044, Business and Professions Code:) The Contractors Li-
cense 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
L cc= Law.
❑ i am exempt under Sec. , B & P C for this reason
Owner Due
WORKERS COMPENSATION DECLARA7ON
hereby affirm under penalty of perjury one of the following declarations
I hsve 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.
❑ i have and will maintain Worker's Compensation Irsurartm as required by Section
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3700 of the Labor Code, for the performance of the work for which this permit is issued
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My Workers Compensation insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
or less.)
I certify that in the performance of the work for which this permit's issued I shall not
employ any
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,)
Lender's Name -
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Lenders Address
I certify that I have read this application and state that the above information is
c correct- 1 agree to comply with all city and county ordinances and state laws relating to
c building constmction, and hereby authorim representatives of this city to enter upon the
ahovc-mentioned property for inspection purposes -
(We) agree to save, indemnify and keep harmless the City of Cupertino against.
j liabilities judgments, toss 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
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Issued by: Date
SOURCE REGULATIONS.
Re -roofs —�� •
Type of Roof
Signature of Applicant/Conuactor Dale
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Murricinal Code. Cbapter 9.12, and the Health and Safety
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Code, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yo
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 hazardrns air contaminants as defmcd by the Bay Area Air Quality Management
all new materials for inspection.
Disvict7
❑ Yes o
I have react the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health &
of Applicant Date
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. All roof coverings to be Class "B" or better
<A r or authorirt:d agent _ Date