08080089CITY OF CUPERTINOr
BUILDING DIVISION PERNUT
BUI IN DRESS:
�/E�Ej�
PERMIT NO.
WEST HILL LN
BENJAMIN GUTIERREZ GENERAL
08080089
:
SANiTARY NO. CONTROL NO.
(510) 432-6249
ARCHIfECUENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Section7000)ofDivlsion3oftheBusinessandProfcssionsCode,andmyliccowis
REVISION—SHR TRANSFER DETAIL @ LOW ROOF TO WALL &
in full force and dfect.
License ClassLick
CONTINUTY @ STAIRCASE HORZTL OPNG ORIG407120278—
Date Contractor
ARCHITECTS DECLARATION
NO
I understand my plans shall be used as public records
NEW PERMIT.
Licensed Professional
' . OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractar's License Law for the
following reason. (Section 7031.5. Busher: and Professions Code: 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
the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of
O
(commenting 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
3 6227020.W Number
Occupancy
P.erne Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mote than five hundred dollars (Ssoo).
❑ L as owner of the property, or my employees with wages as their sale compensation,
Required Inspections
will do the worst, and the snuctme is not intended or offered for sale (Sec. 7044, Businew
and Professions Cnae: The Conuactoes L.icanse Law does rat apply o an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements arc not intended or offered for sale. it.
however, the building or improvement is sold within one year of completion, the owner.
builder will have the birders of proving that he did not build or improve for purpose of
sale.).
❑ L as owner of the property, am exclusively contracting with Bceased contractors to
corturoct the project (Sec 7044. Business and Professions Code.) The Contractor's 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
License Law.
❑ 1 am exempt under Sec.I , B & P C far this reason
7
Owner ./" _' Date � d
'ORKERS OMP SATION 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 Worker's Compen-
:atom, 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 Workers Compensation insurance, as required by Section
3700 of the Labor Coda 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 EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars (S 100)
or less.)
I certify that In the performance of the work for which this permit is issued, 1 shall not
employ arty person in any manner so as tobecome subject to the Workers' Comprsation
Laws of California. Date
Applicant iLi—
NOTICE TO APPLICANT: If, a making kLiCortficaac of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shag be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby rdrnm that there is a convection lending agency for the performance of
the work for which this permit is Issued (Sec. 3097, Civ. C)
Lenders Name
Lender's Address
1 certify that I have mad this application and state that the above information is
correct-1 agree to empply with all city and county ordinances and state Laws relating to
building convection, and hereby authorize representatives of this city to enter upon the
above-mentioeed property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may In any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COM1L.Y WITH ALL NON -POINT
SOURCE REGULATIONS.
p
Issued by: Date
-� 9—Dam
Re -roofs
Type of Roof
Signature of ApplianUContracto
HAZARDOUS MATERIALS S DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(.)7
❑Yes No
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 of future building occupant use equipment or devices which
craft hazardous air contaminants as defined by the Bay Arcs Air Quality Management
all new materials for inspection.
District? /
❑Yes
1 have read the hazardous materials requircr a= under Chapter 6.95 of the Califor.
ma Health & Safety Cock, Sections 25505. 25533 and 25534.1 understand that if the building
does nor currently have a!p rant, that It is my responsibility to notify the occupant of the
requirements which m rube men prior to issaan r:bf a certificate of QTgranQ-
Signature of Applicant Date
f
All roof coverings to be Class'n" or better
� Date'
Owner or authorvtd agent