07040063CITY OF CUPERTINO
DIVISION PERmia4�k�0.tiC71V�RIYxf?a�ti
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BUILDING
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PHON
RD
S y CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fora and effect _
j O Lic. p-.0
License Class 1 �1d
ELECTRICAL SERVICE TO NEW MODULAR COMMERCIAL
Date Contractor 96e nlrlirrl
TRAILER.
ARCHITECTS ECLARATION
1 understand my plans shall az pul,M
Licensed Professional
OWNER -BUILDER DECLARATIO
1 hereby affrm that I am exempt from the Conuacmr's License Law for the
following mason. (Section 7031.5, Business and Professions 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 file a signed statement
Sq. Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencingwith Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt dtetefrom and the basis for the a lcgcd exemption. Any violation of
APN Number
Occupancy Type
Seglon 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than fire hundred dollars ($SM.
❑ 1, as owner of the property, or my employees with wages as arcir sole compensation,
31606033.00
Required Inspections
will do the wort- and the smicture is not intended or offered for sale (Sec. 7044, Business
dots not apply to an ownof
and Professors Code: The Contractor's License Laws
q P
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 preying that he did not build or improve for purpose of
sales).
❑ 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-
ecrae Law does not apply to an owner of property who builds or improves thereon, and,
who contacts for such projeaa with a conuwtor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec . B & P C for this reason
Owner Date
WORKER'S COMPF-NSA71ON DECLARATION
1 heeby 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.
❑ 1 have and will maintain Worker's Comperucation Insurance, as required by Section
3700 of the Labor Code, for the performance of the wort for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are: �I -��y�y
Canier-� -C Polley No.: VM VQ (�'—
CERTIFICATE OF EXEMiiT70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this p=it is Wucd, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of Califomla Date
Applicant
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
forthwith comply with such provisions or this permit shall be deemed mvokcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consuucdon lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
-
L criders Address
1 certify that 1 have read ibis 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-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities. Judgments, c a and expense which may in any way accrue against said City
inconsequence granting of this permit.
APPLICA ERSTAND D WILL COMPLY WITH ALL NON -POINT
/
Issued by: Date J ��
SOURCE Tf0
7
Re -roofs
Type of Roof
Signature A ianUConract Date
HAZARD S MATERIALS DISCLOSURE
Will the applicant or future bullding occupant store or handle hazardous material
as damned by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safely
Code, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ � Yes o
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or rutum building occupant use
PP g Pa equipment rn devirrs which
emit hazardous air contaminants as defined by ibc Bay Area Air Quality Management
all new materials for inspection.
District? �
Yes
❑ (13No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
niaHcalth&SafctyCoxlc, 25505,25533and25534.I mdcrsanddratlfUnc building
does riot cmrcndy t drat it ', risibility to ratify the occupant of the
requirements which metpri xnracQ,iheateero
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
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