071202714
CITY OF CUPERTINOBUILDING
DIVISION PET
Buap�r�c�5�gjrEs OLUMBUS AVE
DANG' S CONSTRUCTION
PERMrr 07120271
„
3805 MASTERS CT
ONE:
SANITARY NO. CONTROL NO.
(408)365-8615
ARCHITECI'/ENGINEER:
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BUILDING PERMIT INFO
Eo �O MECH
O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
bemby affirm Nat I am licensed under provision of Caspar 9 (commencing
with Section 70110) ofDivislon 3 of the Buainett and Professions Code, and my limnw is
EXTND EXSTNG SEWER LINE; ADDING SUMP PUMP
in full fame Mainlines.
License Class Lie. g
Dam Comtacier
ARCHr1ECrS DECLARATION
1 understand my plans shall M used as public mcords
Licensed Prefessim d
OWNER -BUILDER DECLARATION
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1 hereby afTrm that 1 am exempt treat the Contractors License Law for the
following mews. (Section 7031.5. Buaienss and Professions Cade: Any city or county
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which requires a permit in construct. alcor, hnpmve, demolish, or repair my e4uomm
prior t its issuance, also requima the applicant (asuch permit to rile asigned statement
he is licensed to the of me Customer's Liccmn Law (Clupter9
Sq. Ft. Floor Area
Valuation
that pursuant pwviaioat
� 4000
(commencing with Section 7000) of Division 3 of the Business and Pmfeuians Cub)or
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that he is exempt themfrum and the bub remainder.for the allcgedremainder. Any violation of
3 6 2 04 012 !Vl
Occupancy Type
Section 7014.5 by any applicant for a permit subjects the applicwt to a civil penalty ofNumber
nal mart man five hundred dollars (5500).
❑ 1. as owner order property, a my employees with wages u their sets rompenutian,
Required Inspections
will do lheworl, and the suusnure Is notimm4daroQemtl forma (Sec. 70th, Baalnese
End Pfeulom Cod. The Contractors Litmus Law does an, apply to w owner of
Nm
e ns
q p
property who builds orimprovas mereon,and whodoessuchworkhimselfor Waugh his
awn employees. provided that such improvements am net intended moRemd forsale. if,
bow.,. an building orimprevement is veld within am year of osmplamm, me owner-
buitder will have the burden of peoving that he did not bold or improve for purpose of
sale.).
❑ 1. as owner of the property, am caressively cmuacting with licensed conuaamrs to
construct doe project (Sea 7064, Business and Profesalan Cade:) The Co mumar's LI -
cense Law dao not apply as en owner of property who builds or impmw mamma, and,
who contracts for such project, wit a contractors) tkenud pursuant m me Constar's
License Law
am ere
DECLARATION
I hereby afam under penalty of perjury can of the fallowing Owlumoos:
❑ 1 have and will maintain a Certificate of Consent in self-insum for WorkersCompen-
sation, as provided for by Section 37x0 of the labor Code. fm the performance of the
wank for which this permit is issued
❑ I have and will maintain Worker's Compensation Insuowce, as required by Section
3700 of me Labor Code, for the performwee of the weak forwhich this permit is Issued.
My Workers Compression Insurance carrier ad Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mrissoc m need alt W completed iflhe permit Is faomhundmd dollars ($100)
—
m [Cm)
1 certify mat In the performance of this work for which this permit b ismand. I shall not
employany permn inwyfwannerw utbrcomesubject toW Works. alpensa0an
Laws of California. n." I
Apple -� ssif
f Erl
NVC6 O�C making al—blCen�ifirnaest
APP a xe�. rt-onv, you should
become Subject t the okes Ca pemkdon provisions of me Labor Coda you most
forthwith comply with such provisions or this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
1 heathy affirm meat b ro agency for the Performance of
(Sce. 30 7, Cing
the work for which Otis permit b iatmd (Sea 3097, Civ. C.)
pe s
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Lenders
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Iratlers Add.
j 1 unify mat I have road this application and tut that the above information is
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comet. I agree a comply with all city and county oee mums, and one laws mating to
Wilding convection. and hereby authorize repmaentstives of this city to occur upon the
above-mentioned property for inspection purposes.
(We) agree t sate. indemnify and keep Nratless the City of Caper iso against
j liabilities,judgments. coats and expenses which way in my way acerae against mid City
m cpapkimusce of the grwfing of this permit.
r A
MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant etre or lundle houndoua material
as defend by W Cupertino Municipal Code. Chapter 9. 12. and the Health and Safety
code, Scctiezss3zra)7
All roofs shall be inspected prior to any roofing material being installed.
Yes ❑Y❑No
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future Wilding occupant use equipment or devices which
emit hazardous air contaminants a defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Ya ❑No
I have mad the heamous materials requirements under Chapter 6.95 ofthe Califor.
niaH 065mciyCade.Scctiom25505,25533od25534.1mdcmundmniflhe Wilding
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does t mnmy hast a unarm, mu it is my msmnaibiliiy to notify fur amupmt of thc
rMpd
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