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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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PERMIT 08010115
SANITARY NO. CONTROL NO.
ARCHn=1ENGINEER
BUILDiNO PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARA71ON
Job Description
P
1 hereby affirm that I am Hemmed under provisions of Chapter 9 (commencing
with Section 70M of Division 3 ofthe susiriesa and Professions Code, and my license is
ADD 657 SQ ADDITION OF MASTER SUITE, WALK IN
in full force and effect -
License, Chum Lle.I
CLOSET, MASTER BATH, NOOK
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans sball be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
.
I hereby affirm that 1 am a mpt 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 conauucl, alter, improve, demolish, or repair any structure
prior to its issuance, also requites the applicant for such permit to rile a signed statement
he licensed the Contractors Licenser Law (Chapter 9
Sq. Ft. Floor Area Valuation
that is pursuant to the previsions of
7000) Division 3 Business Professions Code) or
$ 2 5 0 0 0 0
(commencing with Section of of the and
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a Civil penalty of
A,;5 Number Occupancy Type
32637020,
am more than five hundred dollars CS5(X .
C
❑ L as owom of the property, or my aopicyces with wages as their sole compensadon,
will do the work, and the structure is not intended or offered for sale (Sec.7044, Business
Required Inspections
and Professions Code: The Contractors Lice>ue Lora does rhos apply to an owner of
property who builds or improves thereon, and who does such wont himself or through his
own employees, provided that such improvements are not intended or offered for air. 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
ales)
Qf L as owner of the property. am exclusivrlyeontntcting with licensed conwtwra to
cortstruc[ the prejett (Sec 7044. Business and Professions Code:) The Contractmrs LI-
cam Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a cons actWs) licensed pursuant to the Contactors
License LAW.
0 1 am exempt under Sec B & P C for this
Owner `� �
DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Cardfieate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code. for the pesformana of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation lonwance, as required by Senion
3700 of the Labor Code, for the performance of the work for which this permit is Issued
'
My Workers Compensation Insurance carrier and Policy number am:
-
carrier. Policy No.:
CERTIFICATE OF EXEMFnON FROM WORKERS
COMPENSATION INSURANCE
(This section teed not be completed If the permit is for one hundred dollars ($100)
or lrss.)
1 certify that in the perfornanee of the work for which this permit is issued, I shall not
-
employ any person io any m so a<la be subj the Wo 'Cum tan
Laws or California. Darc
Applicant
NOTICE TO APPLICANT: lr, after making this Certificate or Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
' forthwith comply with such provisions or this pexmil shall be de med mvokcd.
1
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit Is issued (See. San, Civ. C.)
Lenders Name
Landers Address
j I certify that 1 have read this application and sate that the above information is
' correct 1 agree to comply with all city and county ordinances and sate laws relating to
buildlog construction, and hereby authorize represenalives of this city to enter upon the
)
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may In any way acme against said City
in consequence of the granting of this permIL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date �
SOUR EGULATI INS.
I
Re -roofs
Signature o lieam/Comractor te
HAZARDOUS MATERIAL DISCLOSURE
�„•/
Type of Roof
Will the applicant or future building occupant store or hantfle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
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.
District?
eNo
❑ Yes
1 have read the hazardous materials requirements under Chapta6.95 of the Califor-
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 undersand that if the building
dues not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to Lssftcc of a ceniF:ate of
ignature of Applicant Date
�Uo
All roof coverings to be Class'%W'' or better
Owner orautho agent tof