09030022CITY OF CUPERTINO��,�7�
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BUILDING DIVISION PERT T
BUILDING ADDRESS:
PERMrr NO.
22330 HOMESTEAD
LEWIS
OWNER'S NAME_
'
PERMIT L%UE DATE
PHO
A CONTROL NO.
408)371-6690
ARCHITECT/ENGINEER
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that I am licensed under provision of Chapter 9 (commencing
with Section 70(10) of Division 3 of the Busineaa� Co n I license is
ioore
infullforce S•(p 1l1
License LJc. x
SPLIT MAIN DRAIN
Date Conlracror ,tt+d t 3
ARCHITECTS DECLARATION
I understand my plans shall be used u public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from ibe Contractor's License Law for the
following reason. (Section 70315, Business and Professions Cale: Any city or county
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
that be is licensed pursuant to the provisions of the Contracwrk Lianas Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
6 0 0 0
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
dollars
APN Number
Occupancy
arc
P y Type
Trot more than five hundred (SS00)
32659999
❑ L u 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 sale (Sec. 7044, Business
de: and Professions CaThe Contractors License Law does not apply to an owner of
Required Inspections
property who builds or improves thereon, and who does such work himself or through his
own employca, provided that such improvements are not intended or offered for sale IL
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.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code.,) The Contractor Li -
cone Law does not apply to an owner of property who builds or Improver thereon. and,
who contracts for such projects with a contractors) licensed pursuant to the Contractor
ricer- LAW.
C] I am exempt under Sec B h P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby alarm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker Compen-
sation, as provided for by section 3700 of the Labor code. for the pxrformar= of the
work for which this permit is issued.
❑ I have and will maintain Work ees Compensation insurance, as required by Section
3700 of die Labor Code, for the performance of the work for which this permit is Issues
MyWro• pennti_LUrranacarricralicyN .:qz c?i y+
021-L1tSt> Poky No.: (,� C�00 � l
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed U the permit is for one hundred dollars ($100)
or lcsa)
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 ofCalifomia Due
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject in the Worker Compensation provision of the Labor Code- you must
forthwith comply with such provision or this permit shall be deemed moked.
CONSTRUCTION LENDING AGENCY
I hereby afrom that there is a construction lending agency for the performance of
the wort for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
'
Lender's Address
I certify that 1 have read this application and so= that the above information is
comecL I agree to comply with all city and county ordinances and state laws relating to
building-contruction, and hereby authorize: representatives of this city to enter upon the
xbovKmeritimned for inpeNon purposes
'
MAI ro ve indemnify and keep harmless the City of Cupertino against
halAlid s, J0 ts oats and expenses ' h may In any way accrue against said City
gm it.
rAP.pL.ICANT
ERSTANof
DS AN WILL OMPLY WITH ALL NON -POINT
Issued by: Date
sDL Cs TIONS.
-
6
Re -roofs
—
Type of Roof
• altira of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Wfjl the applicant or future building occupant store or handle hazardous material
43 Ikfie4M by the Cupertino Municipal Code- Chapter 9.12. sad the Health and Safety
C400.5cction 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
ns
If a roof is installed without first obtaining an inspection, I agree to remove
VAN. the applicant or future building occupant use equipment or devices which
cmlt barwdon air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
l7,rstria7
I have the materials rcqu' under Chapter Q 95 of the Califor-
nia kwtO' $cif y Seaton 25505. 25533 1 m dersia .,o that if the building
09cs uSti'corren ve a ==Lt. that it is my 'bill to ratify the occupant of the
ICgcirnncnts w h List x met into rssu �•
3 -(, _Q
Signature of Applicant Date
All roof coverings to be Class'}'' or better
0 Date
sir authorvcd agent