08030060CITY OF CUPERTINO
BUILDING DIVISION PEAT
!:
BUILDING ADDRESS:
PERMIT NO.
7564 ERIN WAY
BD - TO BE DETERMINED
08030060
03/12/2008
PHONE;
SANITARY NO. CONTROL NO.
ARCHIT£CT/FNGiNFER•
BUILDING PERMIT INFO
L BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (Commencing
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with Section 7000) of Division 3 of the Busimss and P f license is
garyl,puy
in full force and effect ��DDf!
License Class Lie -I
'
Date Contractor
ARCHITECPS DECLARATION
1 understand my putts shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby afLrm that I am exempt from the Contractors L9cense Law for We
following reason. (Section 70313, Business and Profession& Coder Any city Or County
which requires a permit to construct, alux, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of We Contractors License Law (Chapter 9
Sq.
(Commencing with Section 7000) of Division 3 of the Business and Profs '_ Code) or
e basis for the alleged exemption. y violation of
that he Is exempt therefrom and WAn
APN 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 (5500).
L, as owner of the property, or my employees with wages u their sole compensation,
Required Inspections
will do the work and the structure is nes intended or offered forsale (Sec. 7044. Business
and Pmfeasloma Coda Tae contractor's License Law does not apply to an owner or
property who builds or improves thereon, and who does such wort himself or through his
own employes, provided that such improvements are nes intended or offered for sale If,
however. the building or improvement is sold within one year of completion. the owner -
builder wN her the burden of proving that he did not build or improve for purpose of
sale.).
L, u owner of the property, am exclusively contracting with licensed contactors 10
construct the project (Sec 7044. Business and Professions Code:) The Contractors Li -
cease Law does our apply to an owner of property who builds or improves thereon, and ,
who contracts for such pmjects with a conuaetot(s) Hceuud pursuant to the Contractors
I Iceme Law.
❑ I w exempt under Sec B & P C for this reason
Owner Dale
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of We following declarations:
❑ I have and will maintain a Certificate of Consent to self-iuwe far Worlmr s Comport-
sation. u provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit G issued.
I have and will maintain Workers Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued
My World wrier and Polley n sit,
Cartier. SS PoH�y No.: `S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSA17ONINSURANCE
(itis sexton meed not be compkmd if the permit is foranc 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 manner so as In become subject to the Workers' Compensation
Laws of Califomia. Date
Applicant
NOTICE TO APPLICANT: If. after milting this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Cade, you mem
forthwith comply with such provisions or this permit shall be deemed revoked
CONsmucriON LENDING AGENCY
I hereby drum that there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Ch. C.)
[.enders Name
Lenders Address
I certify that 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
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 kap harmless the City of Cupertino against
liabilities, judgments, coats and expenses which may in any way accrue against said City
in consequence of the ng of this permit.
of
APPLICANT DS AND WILL COMPLY WITTY ALL NON -POINT
Issued by: Date
SOURCE REG ONS.
7 a-
3
Re -roofs
Type of Roof
Signature of App ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous materiel
as defined by the Cupertino Municipal Code, Chapter 9.12. and We Health and Safety
Code, Section 25532(e)7
❑Yes 01<0
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 or future building occupant use equipment or devices which
.I
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? ��
❑Yes L ITvo
1 have read the materials requirements under Chapter 6.95 of the Califor-
nia Health & Safct , Sections Z55(15.25533 and 755 'understand that if the building
does not have a tenant, it is my ' ity to ratify the oampant of the
rcgai,cmcnts hichmem pn araCertjfga
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Signature of Applicant Date
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All roof coverings to be Class'' or better
Owner or authorized agent Dam