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CITY OF CUPERTINO
BUILDING DIVISION PERM
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BUILDING ADDRESS:
PERMIT NO. 05080044
10200 EMPIRE AV
OWNER'
02 10 2006
_
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
hereby Chapter 9
Job Description
I affirm that I am licensed under provisions of (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
ADD 9731 2 ND FLR / 3 9 6 1 GARAGE)
Dte LicenseClass Conti
Date Contractor
MASTERBEDRM/BATH/LOFT—REMODEL 1,2801
ARCHITECTS DECLARATION
FAMILY RM/DINING/STUDY/BEDRM/BATH
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a pcmtit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant forsuch permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) ur
$ 3 5 9 9 6 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered 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 work 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
).
[
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property -who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain aCertificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Polity number arc:
Carrier: Polity No.:
CERTIFICATE OFEXEMPTTON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or Icss.)
I certify that in the performance of the work for which this per it is issued, I shall not
employ any
of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall 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.)
Lender's Name
,
Lender's Address
1 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
building construction, and hereby authorize representatives of this city to enter upon the
ahove-memioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, costs and expenses which may in any way accrue againstsaid City
in consequence of the granting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N-POINT
l
Issued by: Date--
Z.
Re-roofs
Signamre Applicant/Contractor Date
of
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section25532(a)?
❑Yes � No
All roofs shall be inspected prior to an roofing material being
P P Y g g installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future b ilding occupant use equipment or devices which
emit hazardous air contaminants as cfined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes u
I have read the hazardous materials requirements under Chapter6.95 of the Cali for-
niaHealth&SatetyCode,Sections25505,25533and 25534.1understand that ifthe building
does not
,�up e
Signature ofApplieant Date
All roof coverings to be Class " B" or better
�� /
Owner or authorized age' Dote