08060240CITY OF CUPEKI'INU
BUILDING DIVISION PERMIT! a
P 90:1WIV
BUI INO DRESS: PERMIT NO.
0 73 GREENLEAF DR TBD - TO BE DETERMINED 08060240
08/27/2008
PHONE: SANITARY NO. CONTROL NO.
ARCHI7ECf?ENGOVEER: B PERMIT INFO
ADD 457 SQ FT BEDROOM, BLDG ELECT G PLLUMB MECH
1 O p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I sm licensed under provisions of Chapter 9 (commencing
M., with Section 700M of Division 3 of dee Business and Professions Code, and my license is
in full force and effect.
O
i License pass _ Lie. M
I F' u9 Date Contractor
` ARCHITECTS DECLARATION
6 1 understand my plans shall be used as public records
)yU
Lu
Licensed Professional
y OWNER -BUILDER DECLARATION
j_ I herby affirm that I am exempt from the Contractor's License Law for the
20 following reason. (Sexton 7031.5, Business and Professions Code: Any city or county
li which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance. also requires the applicant for such permit to file a signed statement
G that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
u$ (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 (5500).
❑ L, as owner of the property, or my croployces with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractor's Lie== Law dors not apply to an owner of
property who builds or improves thereon, and who does such work himselfor through his
own employees, provided that such improvements are not Intended or offered for We, 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.).
10 L, as owner of the property, am exclusively contracting with licensed contractors to
nsttvct 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 contractor(s) licensed pursuant m the Contractor's
License Law.
❑ I am
� Date f1 a
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a.Cenifiate 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 Workees 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 artier and Policy number ate:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S IOO),
or lest)
I certify that In the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers Compensation
Laws of CalifZi
Applicant . /Ca S
NOTICE TO APPLICANT: If. after making this cnlfham of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Codc, you must
.J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z rr CONSTRUCTION LENDING AGENCY
F -r C'n I hereby affirm that there is a construction lending agency for the performance of
p4 > the work for which this permit is issued (Sec. 3097, Civ. C.)
Owe Q Lender's Name
.0 Lender's Address
U 0 1 certify that I have read this application and suite dna the above information is
Gy correct I agree to comply with all City and county ordinances and state laws misting to
0 V building construction, and botchy aurhodre representatives of this city to enter upon the
(Ji above-mentioned property for inspection purposes.
LL (We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way actxue against said City
U z in consequence of the granting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WrrH ALL NON -POINT
SOU a TI' �/ / of
Signatureant/Con r Dale
HAZARDOUS MATERIALS DISCLOSURE
WIB the applicant or future building occupant store or handle hazardous material
as defined bythe Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?
[I Yes We
Will the applicant of future building oceupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air. Quality Management
District?
❑Yes )INo
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hath & Safety Code, Scetiens 25505.25533 and 25534.1 undersand thisif t e building
does not currently have a tenant. that It is my responsibility to notify the occupant of the
mquirSMonts of a Cenificate of Occupancy. _
Ft.
Issued by:
Re -roofs
Type of Roof
Number
Job Description
Required Inspections
Valuation
Type
Date d ~��
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 '}k'r or better