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CITY OF CUPERTINO
DIVISION PERNIIT�3�4.�
BUILDING
Bu1L(i1RT��LORA VISTA AVE
PROVISION DEVELOPMENT
07120024
:
SANITARY NO. CONTROL NO.
(408) 245-0991
ARCHITEC.TIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I Job Description
P
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) ofDivWon 3 ofthe Business and trolmlons and my license is
DEFERRED —ROOF TRUSS & CALC. ORIG PERMIT 07030044
in full force and eff
Lice Cl Lle.N
NO NEW PERMIT CORRECTED DOLLAR AMT REC
Date On ARCH IIECCo D7WC noN a
B S 0 0 0 0 0 3 4 8 3
I understand my plans shall be used as public records
2,896.05 IS THE CORRECT AMT THEY PD . THEIR
RECEIPT
Licensed Professional
OWNER -BUILDER Dtx1ARAT10N
I hereby affirm that I am exempt from the Contractor's License Law for the
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolLsh, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
the of the Contractor's License Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to previsions (Chapter
7000) Division 3 the Business Professions Code)
$ 0
(commencing with Section of of and or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 2 6 0 8 0 2 0 ! Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applcant to a civil penalty of
not momthan five hundred dollars (M).
❑ 1, as owner of the property, or my employers with wages as their sate compensation,
Required Inspections
will do the work and the structure is not intended oroffered for sale (Sec.70".Business
and Profession& Code: The Contractors License Law does not apply to an owner of
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property who builds or improves thereon, and who does such work himself ar through his
Own tmtployem provided that such improvemerrta arc not intended or offered for sale. U.
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 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.
❑ I am exempt under Sec B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compenn-
sadon, as provided for by Section 3700 of the Labor Cook, for the performance of the
work for which this permit IS issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is tarred.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier.. RN P _ Polity No.: 7/ 3 0 i0 1 4-r 1 7
FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
07tis section need not be completed if the permit is foram hundred dollars ($100)
or less)
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 is to become subject to the Workers' 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 affirm that there is a construction Lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
L.cnders Address
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and stale laws relating to
building 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 harmless the Cit tyna against
liabilities. judgments. costs and expcases which may i ace g trot said City
of the granting of this A
APPLICPLIC ANTNT UNDERSTAND ILL C WITH ALL NON -POINT
Issued by: Date "JL
SOURCE REGULKI I
Re -roofs
Type of Roof
s a rcanuContractor adc
HAZARDOUS MATERIALS DISCLOSURE D
Will the applicant or future building occupant store or handle hrmrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
case, section 25532(a)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,agree to remove
Will the applicant car rutum building Occupant use
pp g pan equipment or devices which
emit hazardous air contaminants as defined by the Bay Ama Air Quality Management
.I
all new materials for inspection.
District?
❑ Yes 9,No
I have read the hazardous materials r rats and per 6.95 of the Califor-
nia Health & Safety Code, Sections SBJ Sa533 an 1 understand that if the building
i
deer not currently have rat, that it slb(lity a. nodfy the occupant of the
requirements ust be ce of a Certificate or
/ 3) og'
Signature, of Applicant Date
All roof coverings to be Class "B' or better
Owner Date
or authorized agent