05120047BUILDING DIVISION PERMIT
NAME:
that 1 am
Lie. N,o.
CIs r
plans shall be used as public tcenrda
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt form the Convenors License Law for the
following mason. (Section 7071.5, Business and Profstluns Cork: Any city or county
which rotor. a Permit to cnnsumet, eller, improve, demolub. ver repair any ssmcmm
prior to its issuance. also requires the applicant forsuch Permit o File a signed statement
that Inc is licensed Pursuant o the p.visimatt f the Contractor', Lee. law (Chapter 9
(commencing with Section 7000) of Division 7 of Ne Businessmd Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7071.5 by any applicant for a Permit subjects the applicant to a civil penalty of
nm mart Nan five hundred dollars (Ms.
❑ 1. as owner of the prop,ny, or my employees with wages a Bmir sole compensation,
will do the work. and the swewre u not intended or offered for We (Sec. 7044, Business
and Professions Cade: The Conuxtors License Taw does not apply to in owner of
propeny who builds or improves thereon, and who doessueh work himself orthrough his
Own employ=, provided that such improvements are natintendW reoffered for sale. If.
however, Use building or improvement is old within one year of completion, Ne owner.
builder will ban Ne human of proving that he did not Wild or improve for purpose of
I.
as owner of the propcny, am exclusively contracting with licensed contractors to
comma m project (Bac. 7044, Business and Profession Cade:) lle Contractor's Li.
,cmc taw does not aPP1Y to an comer of properwho Wilds of improves hereon. and
who ebnsnM for such projeeta with a eontraetor(s) licensed pursuant to the Convsesoh
License law.
1 am exempt under Sec. , B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declamtioos:
an and will maintain aCmiriaam, of Consent o self -insure for Worker's Comport-
, as Provided for by Section 7700 of the labor Code, for de performance of the
work for which this permit is issued.
1 ban and will maintain Workers Compensation Inwrantt, as required by Section
37W of Ne labor Code, for the Performance of the work for which this permit is issued.
My Worker's Comp ration IOa!L n. ca is and Policy n rob r
Carver. IPolicy No.:
CERTI CA OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu=Iran need trot beemnp1mcd if Ne permit is foram, hundred dollars (SIM)
nrka..)
I ttnify thm in the ptrionnance of the work for which this Permit is issued. I shall not
employ any Peron in any manner an, a to become subject to the Workera'Compensation
Laws of Colifmout. Dare
Applicant
NOTICE TO APPLICANT. IL after making this Cenifcam of Exemption, you should
become subject to the Worker's Compensstion previsions of the Labor Code, you most
J z fodrwith comply with such provisions or this permit about he deemed revoked.
O
C�i CONSTRUCTION LENDING AGENCY
I hereby affirm that Here is a construction lending aBcra7
for the
Performance or
the wvh for which this parrots is issued (Sea 3091. Ci, C.)
GA Lenders Name
7 z Lender's Address
U O 1 cenify that I ban read this application and mm that the above information I,
ty H correct. l agree to comply with all city and county ordinances and stale laws relating to
O V Wilding construction, and hereby authorim Mptsenulives of this city to enter upon Oc
a Wve mentioned Progeny for inspection purposes.
H y (We) agree to an, indemnify and k,cP harmless the City of Cupertino against
f/1 liebilities,juddmcn ,cots and expcnsea which may, in any wayattme aivt wO City
U'� inconsequence e6 ting mf NiJj pepnit.
APPI�ICO4NT DEETAfIDS/l17g'WILL COMPLY WITH AZNOA-POINT
Will the applicant or future building oecupantstore or h96dle Woodous material
as daft by the Cupertino Municip-1 Code, Chapter 9.13, and Ne Health and Safety
Will the applicant or future Wilding Occupant use equipment or devices which
vardnus air eonumivns as"'jainscal by the Bay Area Air Quality Management
❑Yes No
Ihavemadtheh:n nus marerialsmyuimmcns under Choprer6.95 of tht
w&�s.rtty ScetionyBScff).5. ssf53 anal 35574.1anamand Nvirthe
PACIFIC GENERAL CONSTRUCTIMr"OS120047
Is., WUC UAIG
BUILDING
Job Description
REVISION --SHELL ELECTRICAL
NO NEW PERMIT ISSUED/ORIG. #03100011
(19622 - 19638 STEVENS CRK BLVD)
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date
$0
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
W