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13UiLDING DIVISION
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RAYMOND YIP
P08010172
OWNER'S NAME:
PERMIT ISSUE DATE
RAYMOND
NO. CONTROL NO.
ARCHITECTfFNGINEER:
BUILDING PERMrrrNFO
BL.DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
RMDL KTC HN & BTHRMS , NON- STRUCTRL ; INC LD
in Licenseull force and Classarc
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ELEC / MECH / PLMB
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Buslmcss and Professions Code: Any city or county
which requires a permit to construct, alter, improve. demolWt, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the of the Contractors Lxcnsc Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions
Section 7000) of Division 3 of the Business and Professions Code) or
10 0 0 0
(commencing with
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
,� Number
36210025.
O
Occupancy 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 (ssoo).
❑ 1, as owner of the property, err my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or ofre and for sale (Sec. 7044, Business
and Professions code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such wort himself or through his
own 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
sakJ.
as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions CodoJ The Conntracsors U.
tense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
❑ I am exempt under
'S COMPENrHON DECLARATION
I hereby &(firm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compen-
section, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued_
❑ I have and will maintain Workers Compensaion insurance, as required by Section
3700 of the Labor Cale, for the performance of the work for which this permit is issued
'
My Workers Compensation Insurance carrier and Policy numberare:
Carrier: Policy No.:
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(LhLs section need riot be completed If the permit Is for one hundred dollars (S 100)
or less.)
I cenify that in the performance of the work for which this permit is issued 1 shall not
employ any person in any manner so a rlpct to the Worloers' Compensation
Laws of California Date
Applicant p? v
NOTICE
subject to the Workers Compensation provisions of the Labor Code, you must
-
forthwith comply with such provisions or this permit shalt 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.)
-
Lenders Namc
,
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
budding construction, and hereby authorize representatives or this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilideu,judgments, costa and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE MULAIIONS.
Re -
Signature ofApplicanl ontractor Date
HAZARDOUS MA Ass DISCLOSURE
Will the applicant or future building occulml store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7_
All roofs shall be inspected prior to any roofing material being installed.
❑ Yea
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment err devices which
emit hazardous air contaminants as defined y the Bay Area Air Quality Management
District]
all new materials for inspection.
❑ Yes u
I have read the hazardous materials requirements under Chapter 6.95 of the Califor•
nia Health & Safety Codc, Sections 25505, 25533 and 25534.1 understand that If the building
does not currently have a arsons. that It is my responsibility to notify the occupant or the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
71 ° ' ����
All roof coverings to be Class "B" or better
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Owner or wtho d agent arc