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CITY OF CUPERTINO
BUILDING DIVISION PERIVIIT`�,
BUILDING ADDRESS:
PERMIT NO.
20800 HOMEHOMESTRAD ED
WEST
OWNER'S NAME:
PERMIT ISSUE DAIS
PHO
S CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
REVISE TRUSS CALCS' ORIG#
BLDG ELECT PLUMB MECH
o o O 0
LICENSED CONTRACTOR'S DECLARATION
0 712 0 212 —NO NEW PERM]]�b Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Busineaa and Prof es 'ons Code, and nae is
=ylke
in full face and effect. 3
License Class Lie. 0
S '
Date a . in Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER-BURDER DECLARATION
I hereby affirm 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 structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basin for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by arty applicant for a permit subjecu the applicant to a civil penalty of
not mote than five hundred dollars (MMI
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements arc 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
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 Ll-
cenae Law does not apply to an owner of property who builds or Improves thereon, and,
who contracts for such projects with a conuacmr(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B & P C for this reason
Owner Due
WORKERS COMPENSATION DECLARATION
1 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 Compen-
sadon, as provided for by Section 3700 of the labor Code, 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 issued.
'
My Worker Com ensati n insurance carrier and Policy number are:
-It1
0�
Canis: Policy No.: `
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
.
or less.)
1 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 to become subject to the Workers Compensation
Laws of California Due
Appficam
NOTICE TO APPLICANT: if, all" 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
1 hemby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's 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 c 'on, and hereby authorize represernradva of this city to enter upon the
about -me red property for inspection purposes.
(W) to save, indemnify and keep harmless the City of Cupertino against
liabilities, meals, touts and expenses which may in any way accrue against said City
in co the granting Of" permit.
APP A U ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOU ON . �1'D1
�'
Re -roofs
—
Type of Roof
Signature ppli UCant Or Date
tiAZARDOUS MATERIALS DISCLOSURE
appliant or future Tiding ooxvpant store or handle hazardous material
as defined by tbe Cupertino M pal Code, Chapter 9.12, and the Health and Safety
Ctxle, season 25532(a)7
All roofs shall be inspected. prior to any roofing material being installed.
❑Yea No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Iding occupant use equipment or devices which
cmh hazardous air contamirtanu defined by the Bay Area Air Quality Management
all new materials for inspection.
Diwrict7
❑ Yes Nu
Ih materialsrequirements under Chapt"6.95oftheCaiifor-
niaHalth& cs255o5.25533and 25534.1un�andthuifthebuilding
rh�aaicnant.
does n c ntiy that it is my responsilrility ro notify the occupant of the
rcga;m n or to issuance of a Cenificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class '%'` or better
Dam
Owner or agent