09040066CTTY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
7834 RO
OWNER'S NAME:
ARCHn=/ENGINEER:
3 cep 7,C LICENSED CONTRACTOR'S DECLARATION
U c I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z with Section 7000) of Division 3 of the Business and Professions Code, and my license is
= un in full force and effect.
ern z License Class Lie. N
'"ea Date Contractor
3 �' ARCHITECT'S DECLARATION
` I understand my plans shall be used as public records
JWQ
r. U.U. w Licensed Professional
,n S OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt (rum the Contractor's License Law for ttx
00 following reason. (Section 7031.5, Business and Professions Code: Any city or county
K m which requires a permit to rnnsuuc4 alter, improve, demolish, or mpuir any structure
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
F- $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
y .. that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (MI
❑ I, as owner of the property, or my employees with wages as Weir sole compensation,
will do the won, 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
awn 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
sale_).
fnI, as owner of the property. am exclusively contracting with licensed contractors to
struct the project (Sec 7044, Business and Professions Code:) The Contractors Li-
cense law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contracior(s) licensed pursuant to the Contractors
License Law.
❑ I
I hereby affirm under penalty of perjury one of thc following declaral ons:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compc r
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
[j 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 carries and Policy number are:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhis section need not be completed if the permit Is for one hundred dollars (S 10G)
or less)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner s -
should
become subject to the Workers Compensation provisions of the Labor Code, you must
Oforthwith comply with such provisions or this permil shall be deemed revoked.
CONSTRUCTION LEND[NG AGENCY
...�.
E-c 1 hereby affirm that (here is a consuuctinn lending agency for cite performance of
p� > the work for which this permit is issued (Sec. 3097, Civ. C)
ifs. Q Lenders Namc
Z (-enders Address
(� Q 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 relating to
building construction, and hereby authorize representatives of this city to cuter upon the
.0 U
GL1 above -mentioned property for irspenion purposes.
(We) agree to save. indemnify and keep harmless the City of Cupertino against
rn liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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
Cook, Section 25532(a)?
❑Yes 1PNo
Will the applicant or future building occupant use equipment or dcvi= which
emit hazardous air contaminants as defined by the Bay Area Air Quality Mmagcmcnr
District?
❑Yes )§Nu
I have read the hazardous materials requirements under Chapicr6.95 of thc Califor-
nia Health & Safety Codc, Sections 25505, 25533 and 2M34. I understand that dine building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
e
1 : IY1S�'IIl�►.I7
PERMIT NO,
gym" _1 r • .
NO.
BUnDING PERMITINF
BLDG ELECT PrUTZB MECH
Job Description
ADD 151SQ FMRM &CNVRT GARG WNDWS TO DOOR & ADD
ADDTL DR TO GARG,RMDL RF(170SQ)& RLOCT WTR HTR NO
RE—RF
q. Ft. Floor
Valuation
APN Number Occupancy Type
36219031.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
c�
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 rem(
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class".. ' or better