07120239CITY OF CUPERTINO ��,{�
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BUILDING DIVISION PEPJMT
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BUIL.q "T%GGLE AVE
TBD — TO BE DETERMINED
PERMIT No.
07120239
:
SANITARY NO. CONTROL NO.
ARCHTTECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
ADD LV RM r BDRM 4 & 5 r BATH 3 & GARAGE;
RMDL KTCHN
in full force and effect.
License Class Luc. I
INTO
O
Date ARCIIrI'ECTS DECLARATION
DINE RM- SANITARY IS SUNNYVALE
' S JURISDICTION.
I understand my plans shill 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, Business and Professions Code: Any city or county
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0
which requires a permit to constnrcL after, rmProvc, ocmauw, or repass any structure
prior to its issuance, also requires the applicant for such permit to file a signed statrmcni
than he is Licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 70DO) of Division 3 of the Business and Prorcasions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500),
❑ L as ovvn r of the property, or my employees with wages as theta sole compensation,
will do the work, and the structure is not intended or offered forsale (Sec, 7044, Business
and Professions Code: The Contractor's License Law doesnot 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 are not intended or offered for sale. B'.
however, the building or improvement is sold within one year of completion, the owner -
builder wIB have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I. as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec- 7044. Business and Professions Code:) The Contractors U-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conuaetor(s) licensed pursuant to the Contractors
[License Law-
❑ I am exem
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-
sation, 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 Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
My Workers Compensation Insurance curia and Polity number are:
Carrier- Policy No.:
CERTIFICATE OF E EMPTION FROM WORKERS
COMPENSA71ONINSURANCE
(rh(s section need not be completed if the permit is for one hundred dollars (S 100)
or less)
I certify that in the performance of the work for which this permit is issued 1 shall no
employ any person in any mannor so u to b�omC suhial to the Workers' C pensation
Laws of California .1
Aprpliant t7i
NOTICE TO APPLICANT: If, after.making is Certificate of Exemption, you 6buld
become subject to the Workers Compensation provisions of the Labor Code, you must
forlhvvilb comply with such provisions or this permit shall be deemed revoked
CONSTRUCnON LENDING AGENCY
I hereby a[fum the there is a construction lending agency for die performance of
the work for which this permit Is issued (Sec. 3097, Civ. C.)
Lenders Name
Lenders Address
I certify that I have read this application and state tbat the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of 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
liabilities, judgments, costs and exposes which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS
' to
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous materiel
as defined by the Cupertino Morticipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7
❑ Yes �rNo
Will the applicant orffuture building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Distnct7
El Yes I�fno
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,
�that
�itt its nobility m notify the occupant of the
rt:quircmr,Pt, w ich must be met 1! issu sec of a CcrtifiFaj?o'- gay: JO V
Owner or authorized agent
Date
Sq. Ft. Floor Area $12 5 0 0 0 Valuation
37527020 . Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy
Date
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
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class'W' or better