07120278D Q
zn
W
CITY OF CUPERTINO
`�,
BUILDING DIVISION PERMIT
`i1as
Bu1LT6c�ttiijpDWE
PERMTr NO.
ST HILL LN
TBD — TO BE DETERMINED
07120278
:
SANITARY NO. CONTROL NO.
ARCHITEC IENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
1 hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 70D0) of Division 3 of the Business and Professions Code, and my license is
NEW TWO STORY HOUSE
in full forte and offect.
License Class Lic.N
NEED CONTRACTOR INFO
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contactors License Law for the
following mason (Section 7031.5, Business and Professions Cade. 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 rile a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70DD) of Division 3 of the Business and Professiom Code) or
$ 3 0 0 0 0 0
that be is exempt therefrom and the basis for the alleged exemption Any violation of
3 6 2 2 7 0 2 0 Number
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S50a)
.'
❑ L as owner of tile property, or my employees with wages as their sole eomperui Ian,
Required Ired Inspections
win do the worit and the structure is not intended or offered for sale (Sec. 7044, Business
and Profession& Code The Contractors L.icam Law does not apply to an owner of
Q p
ply who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If.
however, the building or improvemanl 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
seek.).
L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (See. 7044, Busing and Professions Code:) The Contractors Li-
cense Law don 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
I icense Law.
0 1 amin der S
Sec ,P C or this reason
.
� Date /T
W 'S COMPENSATION DECLARATION
1 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-
sation, 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 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 Worker`s Compensation insurance carrier and Policy number K:
Carrier. Policy No.:
CERTIFICATE OF -EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
.
(i'his section need not be cxtrrtpleted if ire permit is for one hundred dollars ($100)
or less.)
I certify that In the performance of the work for which this permit is issued, 1 shall not
employ any person in any mannerso MID
sm become subject to the Workers' Compensation
Laws of California. hate
Applicant
NOTICE TO APPLICANT'. If. after malcifffilUCertificatc of Fiefnplio& youu should
uld
become subject to the Worker`s Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
i hereby affirm Out there is a construction fending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
'
Lenders Address
1 certify dirt I have read this application and state that the above information is
correct 1 agree to comply with all city and county ordinances and state laws relating to
bulling construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep hatmhsss 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 COMPLY WITH ALL NON -POINT
L
Issued by: Date
SOURCE REGULA7TO�LS.
Re -roofs
Type Of Roof ✓G/
SigoatureafApplianVCerr r pate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑ Yes ;Ja-No
prior
If a roof.is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devises which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yeso
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
ma Health do Safely Code, Sections 25505.25533 and 25534.1 understand dtat if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
requirements whit trsl he met prior issuance of a Ccnificate O Oc agry.
2 IQ
Signature of Applicant Date
_L(
All roof coverings to be Class 'j'` or better
Owner or authorized a Date "