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CITY OF CUPERTINO
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BUILDING DIVISION PERMiT
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JACOBSON DAVI`D R AND SANDRA
Bu)1 DJAIC �gDLtFSS� BLANEY AVE
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U 8 U 4 O 0 4 3
OWNMSUN.
BLANEY AVE
04/07/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHr=/ENGINEER:
BUILDING PEAMrr)NFO
BLDG ELECT PLUMB MECH
LICENSED CON7RACPOWS DECLARATION
Job Description
I hereby affirm duo I am ikonad under provisions of Chapter 9 (commenting
with Section 700M of Division 3 of tho Business and Professions Code, and my license is
ADD 4 2 6 S Q LVNGRM r ENTRY, UTLTY RM
in full force and effect.
License Class Lk. 0
'
Date Contractor
ARCHrTEC 7S DECLARATION
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 reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to casttrrtct alter, imprrne. demolish, or mpair any struetum
.
prier to its issuance. also requires the applicant for such permit to file a signed statement
he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that puts =[ provisions
$ 2 5 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 exemption. Any violation of
316 3 3 0 0 8� Number
Occupancy Type
Section 7031.5 by any applkanL for a permit subjects the applicant to a civil penalty of
ma more dun five hundred dollars ($S00).
❑ L as owner of We property, or my employees with wages as Weir sole compensation,
Required Inspections
will d0 the work, and the structure is mot intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contrscfoet 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 ale. Ir.
however, the building or improvement is sold within one year of completion. the owner -
builder win hie the burden of proving that he did nor build or improve for purpose of
sa ).
L as Owner Of the property, am exclusively contracting with licensed contractors to
construct the poject (Sec. 7044, Business and Professions Code) Tie Contractor's Li-
.
cease Law don not apply to an owner of property who builds or improves thereat. and .
who contracts for such projects with a tsactor(s) nkensed ptoaium to the Contractor's
License Law.
❑ I am exempt
I hereby affirm u ty of perjury one of the following daLrauons
❑ I ha: and will maintain a Caniliate of Conaem to self-insae far Workee3 Compcn-
sadon, as provided for by Section 3700 of the Labor Code. for the performance of the
wort for'whfch this permit is issued.
.
❑ I have and will maintain Worte>'s Compensation Insurance, as requited by Section
3700 Of the labor Code, for the performance of the work for which this permit is issued.
'
My Worker's Compensation Worm carrier m: rier and Polity number a
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Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed Lf the permit is foram hundred dollars ($100)
or Less)
I certify that In the performance of the wort for w '� this permit is' red, [shill not
employ any person in any ma a
should
become subject to the Worker's Compe on provisions of the Labor Code, you must
' forthwith comply with such provisio this permit shall be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
I hereby affirra that there is a construction lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Clv. C-)
Lender's Name
,
1
Lender's Address
j I ratify that I have read this application and stage that the above infannnadun is
n conrecL 1 agree to comply with all city and county ordinances and sole laws misting to
' building construction, and hereby authorim repnesentalhrs of lids city to eater upon We
1
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above -Mentioned property for inspection purpose&
(We) agree to are, indemnify and keep harmless the City of Cupertino against
l Iiabilides jndgmenta, costs and expense which may in any way &cane against aW City
in consequence of the tra tang of this
APPUCANT UNPERSTANDS A LL
tho applicarn futuro budding occupant store a handle hazardous malarial
As defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code. Section 23532(a)7 �No ❑ Yea
r
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will tho applicant or future building Oavpant use equipment or devices which
cmll hZZardom air contaminants as defined by the Bay Arcs Air Quality Management
all new materials for inspection.
DLwict7
Cl Yes ;211�o
1 have lead die hazadous materials menu under Chaperr Q95 of the Califs -
ro,
ma Health & Sai��cL ''CodcSccu 25505, and 25534.1 tinhderaad WY if the building
tea notentsen, se a torunt. It y responsibility rhotify aw/accultnt of the
requirements h mustx err
Signature ofApplicant Date-
All roof coverings to be Class 'j�j'' or better
Owner or wthorved agent f thee