07100207CITY OF CUPERTINO
BUILDING DIVISION p£/,RM_
BUILDI S
DUNBAR DR
PERMIT NO.
TBD — TO BE DETERMINED
07100207
:
SANITARY NO. CONTROL NO.
ARCHFFEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (comrorncmg
with Section 70DO) of Division 3 of the Business and Professions Code, and my liceaseis
NEW S FDWL 3 816 SQ LIVING & 494 SQ GARAGE
in full fora and effect.
.
License Class lie. 0
'
Date Contractor
ARCHITECT-S DECLARATION
I 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
fallowing rcason. (Section 70315, Business and Professions Code: Any city or county
which requires a permit to construc4 tiller. improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed natemew
he is licensed tothe of the Contractor's License Law (Chapta9
Sq. Ft. Floor Area Valuation
that pursuant provisions
84 5 8 8 6
(commencingwith Section 7 of Division 3 or the Business and Professionsm Code)
�`
that he is exempt therefrom and the basis for the alleged exempdon. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil pantry, of
Number Occupancy
3 2 6 3 014 4?� P y Type
not more than five hundred dollars (s500).
❑ I, as owner of the property, or my employees with wages as their sole compensation,
will dothcworleand [be structweIsnut intended oroffered for sale (Sec.7044,Business
Required Inspections
ns
and Professions Code; The Conaactors License Law does not apply toe
an owner Of
q P
property who builds or improves thereon, and who does such work himself or &*a& 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 owoer-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
L as owner of the property, am exclusively contracting with licensed contractors to
c eruct the pm*a (Sec. 7044, Business and Professions Code:) The Coatrames Li-
cense taw 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 Contractor's
License taw.
❑ I an exempt under Se , B &
will maintain aCervLnte of Consent to self -insure for Worker's Compen-
sation, as provided far by Section 3700 of the Labor Code, for the performance of the
work for which Otis permit is issued. .
❑ I have and will maintain Worker's Compensation Insurance, as required by Setion
3700 of the labor Code, for the performance of the work for which this permit is lamed
My Worker's Compensaion Insurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF F7[EMFTION FROM WORKERS
COMPENSATION INSURANCE
Cnrb section need not be completed if the permit is for one hundred doQaa (SIOO)
or Tess.)
I certify that in the performance of the work for which this permit is issued 1 shall not
employ any person in any manpgr sq�s to pecggte subject to the Workcri Compamdon
laws of California. Date _fix/J �y� 17.F�
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
became subject to the Workers Compensation provisions of the Labor Code, you must:
.
forthwith comply with such provisions or this permit shall be deemed revo ed-
)
j CONSTRUC ION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
1
the work for which this permit is Wued (Sec. 3097, Civ. C.)
'
Lender's Name
,
Lenders Address
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws Missing to
building construction. and hereby authorise representatives of this city to enter upon the
1 above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
i liabilities, judgments, costs and expenses which may in any way accrue again said City
' in consequence of the granting of this permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POQPr
Issued by: Date
so
ter(•,
Signature of
MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hmmrdous tnaraial
as defined by the Cupertino Municipal Codc, Chapter 9.12. and the Health and Safety
Code; Senior 25532(a)T
All roofs shall be inspected prior to any roofing material being installed.
El Yes ❑ No
. If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use
PP g P equipment er devices which
emit haiardous air contaminates as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have read the harardau materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the hmldmg
does not currently have a tenant. that it is my responsibility to notify the occupzm of the
require w tute met
be Class "Br' or better
Owner o.�rmorZU;
Dam