080401694
4
0 C
z�
F�
W;
�z
UC
�a
Uz
t-
4
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
;
flR %
BUILDING ADDRESS:
7984 WOODLARK WAY
TBD - TO BE DETERMINED
PFRMrr NO.
08040169
:
SANITARY NO. CONTROL NO.
AR.CRrMCT/ENGTNE$R:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MFCH
LICENSED CONTRACITJR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DO) of Division 3 of the Business and Professions Code. and my liconscis
ADD 759 SQ FT MASTER BEDRM & BATH, BEDROOM,
in full force and aff=L
Liecnse Class A Lie. � l)
FAMILY
Date 61 131 ARCHITECT'SDDECLAxanoN
RM, EXTEND ONE BEDROOM & LIVING, ENTRY & PORCH-
I.nder+andmyplansshallbeusedaspabiicrecords
REMODEL EXISTING DWELLING, LIVING RM, DINING RM,
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby anirot that 1 am exempt from the Contractors 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, or repair any struetore
'
prior to its issuance, also requires the applicant for such pe mil to file a signed statement
he is licensed to the the Contactors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions of
3 0 0 0 0 0
(commencing with Section 70M of Division 3 of the Business and Professions Code) or
that be is exempt therefrom and the basis for the allcicd exemption. Any violation of
um Nber .
3 6 2 0 4 0 3 6.
Occupancy e
P Y 1'S'P
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty Of
not mote than five hundred dollars (55O0),
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work. and. the stntctnre is nabumded or offered forsalc (Sec. 7044, Business
and Professions Code: The Conuactor'a License Law sloes not apply to an owner of
q P
property who builds or improves nhemon, and who does such work himself or thromgh his
own employes, provided that such improvements ate not intended or offered for sale ir,
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-
,
tense 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 , B & P C Ter this reason
ner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm tinder penalty of perjury one of the following declarations
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
salion, as provided for by Section 3700 of the Labor Code, for the perfmrmannx of the
work for which this permit is issued.
I have and will maintain Worker's Compensation Inntramr, as required by Section
of the Labor Code, for the performance of the work for which this permit is issued.
'
My Worker's Compensation lopr,�
FROM WORKERS
COMPENSATION INSURANCE
('This section need not be completed if the permit is for one hundred dollars (S )00)
or less)
I ^"„i fy 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 Worked Compensation
'
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after malting 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 afTrm that there is; construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Lender's Address
i certify that 1 have read this application and state that the above information is
'
cnrem 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 inspeetloa 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
inconsequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
/� b
Issued by: Date G
occupant sore or handle hazardous material
as damned by the Cupertino Municipal Code, Chapter 9.12, and the Health and safety
25532(a)? 0
Code. Section No
Yes
All roofs shall be inspected prior to any roofing material being installed.
�Will
If a roof is installed without first obtaining an inspection, I agree to remove
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?
❑ Yes /�to
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safcty Code, Sections 25505, 25533 and 25534.1 undcn=d that if the building
does