09040015CITY OF CUPERTINO
PERMIT�{�
INFUMTQ►.
BUILDING DIVISION
BUILDING ADDRESS:
PERMIT NO.
20800 HOMESTEAD
TBD — T
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SXMYARYU.CONTROL NO,
ARCHrIEC tENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job DOSCTIptlOn
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effeot.3 { G 1'� �(
License G — Lic. ®,_T
INSTALL SOLAR THERMAL • SYSTEM FOR POOL HEATING.
Dale Contractor 5c,wwd--c —
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm 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, alter, improve, demolish, at repair any structure
Sq. Ft. Floor Area
Valuation
! prior to its issuance, also requires the applicant for such permit to file a signed statement
law 9
that he is licensed pursuant to the previsions of the Contractor's License (Chapter
(commencing with Section 70DO) of Division 3 of the Business and Professions Code) or
9 6 8 7 4
I that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
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 ($500).
32609056 . ALL
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
q P
will do the work, and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended oraRered forsale. 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
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 Contractor's
License Law.
❑ I am exempt under Sea B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers 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 Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workeess Compensation Insurance carrier and Policy number ate: q
J 11412. F""t� Policy No.: OGo 3t 33) 1
Carrier.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far ane hundred dollars ($100)
or less.)
1 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 Workcre Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby of it n that there is a construction lending agency for the performance of
the work for which this peril is issued (Sec. 3097, Civ. C.)
~ Lender's Name
Lender's Address
1 certify that I have read this application and state that the above inforatiun Is
correct. I agree to comply with all city and county ordinances and state laws relating to
~ building construction, and hereby authorize representatives of this city to enter upon the
inspection
Uabove -mentioned property for purposes.
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
City
q liabidities,judgmems, costs and expenses which may in any way accrue against said
7 in consequence of the granting of this permit.
,✓
:1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date (�
SOURCREGULATI �1 I� IO—1
!�Y
Re -roofs �.
Type of Roof
Signature of Appli andContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑Yes XNo
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? —t
❑ Yes yl} o
1 have mad the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 7 5534. 1 understand that if the building
does not currently have a tenant, that it is my responsibility to noddy the occupant or the
myuiref"� which must he et pnorto issuance of a Certificate of Occupancy.
Signature of Applicant Date
J
All roof coverings to be Class". ' or better
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Owner or authorized agent Date '