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CITY OF CUPERTINO
BUILDING DIVISION PERIVIITi
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BUILnWf 'AMBER DR
TBD - TO BE DETERMINED
PERMrr NO.
08050180
OWNER'S NAME:
PE &T iSS'f.+ fE DATE
SANITARY NO. CONTROL NO.
ARC FII7'ECff FSJGLNEi72:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MBCH
LICENSED CONTRACTORS DECLARATION
Job Description
p
I hereby affirm thu I am licensed under provisions of Chapter 9 (commencing
with Section 70fto) of Division 3 of the Business and Professions Code, and my license is
ADD 2 2 9 ' -1 / 2 BATH & 1 B EDRM , INCREASE LIVING
'Lic�C�iaaa�e�eR Ik.N
RM,REMODEL FRONT OF HOUSE,LIVING RM-INCLDS
Date ARCHrIECrrs DEECL.ARA71ON
RE-RF (16 SQ) & STRUCT .
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to eonoruec. alter, improve, demolish, or repair my structure
prior to its issuance, also requires the applicant for such permit to rile a signers statement
the the contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to provisions of
$ 7 3 0 0 0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged rsempthxr. Any violation of
36216002 Number
Occupancy 'Ij�pe
Section 7031-5 by any applicant for a Pump subjects the applicant to it civil penalty of
not more than rive hundred dollars (SS00)
.
❑ L as owner of Use property, or my employers with wager; as their sole compensation,
Required Inspections
will do the wort, and the structure is not intended or offered for We (Sex. 7044, Business
and Professions Cud—_ -ore Contractors Uccnse Law does not apply to an owner of
property who budlds orimproves theeon, and who does such work himself or through his
we employees, provided that such improvements are not intended or offered for sale if.
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
i
sale.).
I
❑ L as owner of the property, am exclusively conumeting with licensed contractors to
i
Construct the project (See. 7044. Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and ,
who conrnets for such projects with a conuactor(s) licensed purswnt to the Contractors
I iaase Law,
❑ I am
j
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hs m and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit is issued.
❑ 1 have and will maintain Workers Cmopesadon Insurance, as required by Section
3700 of the Labor Code, for the performance of the work forwhich this permit is issued
'
My Worker's Compensation Insurance artier and Policy number are:
Cartier. Policy No.:
CE]CIVICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ohis section need not be completed if the permit is for one hundred dollar (S I00)
or less)
I cenifv that in the performance of the work for which this permit is Issued, i sha8 not
employ any person
labor Code, you must
Forthwith comply with such provisions or this permit shun be deemed revoked
)
.
' CONSTRUCTION LENDING AGENCY
1 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)
Lender's Name
Lenders Address
I certify that I have read this appBcsUou and state that the dove information is
' conect. I agree: to comply with all city and county ordinances and stale laws relating to
building construction, and hereby authorize representative of this city to enter upon the
above-mcationed property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
I liawliLi judgments. Cella and expenses which may In any way state against Laid City' in consequence of the granting of this p=MIL
G
' APPLI UNDER
MATERIALS DISCLOSURE
Will the appGant or future building occupant store or handle hazardous material
'i1Yl
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, section 25532(a)T
All roofs shall be inspected prior to any roofing material being installed.
❑yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or Tulsa building occupant use equipment or device which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes )�No
I have read the hazardous materials requirements under Chapter 6.95 of the Cab for-
nia SafSectionsyCode, Sections 25505, 25533 and 25534.1 understand thatif tho building
does of dy have