05090017CITY OF CUPERTINO
BUILDING DIVISION PERIVIIT
(31V
BUILDING ADDRESS:
PERMIT NO.
WELKIN INTERNATIONAL PND
NC 05090017
O A E:
PERMIT ISSUE DATE
BLVD
SANITARY rj 3 0 2�lb&[. NO.
ARCHI7ECTIENGINEER:
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BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
hereby licensed 9
Job Description
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to
affirm that I am under provisions of Chapter (commencing
with Section 7") of Division 3 of the Business and Professions Code, and my license is
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in full force and effect.
License Class Lie-#
ADD/REMODEL/RELOCATE KITCHEN -1ST FLR 960'
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ui
Date Contractor
ARCHITECTS DECLARATION
2ND FL-659' -FAMILY/BED-BATH/LAUNDRY
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I understand my plans shall be used as public records
Liccnscd Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
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following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
>'
a
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
m(commencing
with Section 7000) of Division 3 of the Business and Professions Code) or
$ 6 4 6 7 9 7
. 4
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 five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered forsale (Sec. N 44, Business
Required Inspections
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 employers, 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 Ute burden of proving that he did not build or improve for purpose of
sale.).
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Conuaetor'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 contramor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this mason
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/ Owner -��.. ,'� Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate 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.
❑ I 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 Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he 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 not
employ, any person in any manner so as tp beeo'�c subject to the Workers' Compensation
Laws of California. Date S
Applicant <'_7/--r fA�.Z 7
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
0
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.)
0 Lender's Name
z Lender's Address
0 I testify that I have read this application and state that the above infomtatiun is
Hcorrect 1 agree to comply with all city and county ordinances and state laws relating to
U building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
LL (We) agree to save, indemnify and keep harmless the City of Cupertino against
r,/) liabilities, judgments, costs and expenseswhich may inany way acerucagainst said City
z in consequence of the granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by:
Signature of Applican`vodri r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yeso
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes J No
1 have read the hazardous materials requirements undcrChapter 6.95 of the Califor.
nia Hcaldr & SafetyCodc. Sections 255D5.25533 and 25534.1 understand that if the building
does not currently hays a tenant, that it is my responsibility to notify the occupant of the
requirements whlrh mt_�
or authorized agent : i 3 Date
Re -roofs
Type of Roof
Date S c) 6, ^='
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 "B" or better