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CITY OF CUPERTINO
BUILDING DIVISION PERT MI+O?"RU
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BUT G DRFSS:
%�1ROBINDELL
PERMIT NO.
WAY
TBD — TO BE DETERMINED
08070208
OWNER'S NAME:
PERTW ISSUE DATE
07/29/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCHrreC IENCITNEEW
BULLRING PERMIT INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I licensed Chapter 9
Job Description
1 hereby affirm that am under provisions of (comm."ll
With Section 70(10) of Division 3 of the Business and Professions Code, ad my ticensc is
ADD 3 6 S Q ENTR & RMDL BTH , ENTRY
in full force and effect.
Ldcww Class Lic. s
Date Contractor
ARCHrrEC`S DECLARA71ON
I understand my plans shall be used as public records
Licensed Professional
OWNER-BUrII)ER DECLARATION
I bercby arrirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031-5, Business and Profcssiors Code: Any city or county
which requires a permit to construct, alter, improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
he is licensed to the the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
char pursuant previsions of
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
2
$ 0 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 6 2 2 3 011 � Number
Occupancy e
P Y TYP
Section 7031.5 by any apoicam for a permit subjects the applicant to it civil penalty of
s asom. not more than fma hundred dollar
❑ 1, as owner of the property, or my employee with wages as their sole compensation,
Required Inspections
will do the wort, and the structure is not intended or offered for sale (Sec 7044. Business
and Professions Code: The Conractors License Law doe not apply to an owner or
property who bads or improves thercon, and who doe such work himself or thmugh his
own employees, provided that such improvements arc not intended or offered for sale. if,
.
bowrver, the Molding Or irmprovement is sold within one year of completion. the owrter-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
Vas owner or the property. am exciusivtly contracting with bcensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractors IS -
cease Law does not apply to an owner of property who builds or improves thercon, and
who contracts for sureh pro' with a Lrontractor(a) licensed pursuant ta [be Contractors
L.icertae Law.
❑ 1 am
❑ 1 have and wiCertificate 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 CampensaLlon Insurance, as required by Section
3700 or the Labor Code, rot the performance or the work for which this permit is issued
'
My Workers Cumpenution hsuraruz carrier and Policy number art:
Carrier. Policy No.:
CEKrIFICATE 5FI7CEMPnON FROM WORKERS
COMPENSATION INSURANCE
(this section need not be completed if the permit is forone hundred dollars ($100)
Or less.)
I certify that in the performance
, you must
forthwith comply with such provisionslor this permit shall be deemed revoked.
CONSTRUCf70N LENDING AGENCY
I hereby affutn that there Is ■ construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
I certify that I have read this application and state that the above information is
.
con=L I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this City to enter upon the
above-mendoned property for inspection purposes
(We) agree to save, Indemnify and keep harmless the City or Cupertino against
liabilities, judgmentst1tu and expenses which may in any way accrue against said City
in consegmlrree of t* inanting of this permlL
APPLICANT
-roofs
Type of Roof
a
Signature of ma'KAZ L MATERIALS DISCLOSURE
VI0 the applicant r future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section zss3z(a)7
❑ Yes
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 the applicant or future Molding occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes 04.1,
ous ff" ttis requirements under Chapter or the Califor-
I have mad y Q
nia Health & Safi Sea. 505.25533 and 25534.1 understand that If the building
don not currrntl ■ tense
Signature of Applicant Date
All roof coverings to be Class "A" or better