07040151BUILDING DIVISION PE RAU
BUnTfiM'g ATALANO CT LOT 5 I GREATER BAY CONSTRUCTION
ARCHITECr/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
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 force and effect.
License classlie-k
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
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
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 Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SSW).
❑ L 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 for sale (Sec. 7G", Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or throngh 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
sale.).
�1, as owner of the properly, am exclusively contracting with licensed contractors;to
truct the project (Sec. 70". Business and Professions Cock:) The Contractors tl-
ceose Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractor(s) licumd pursuant to the Contractor's
License Law.
❑ 1 am en t under Sea , B & P C for this reason
Owner Date
'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen.
sation, as provided for by Section 3700 of the Libor 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 Workers Compensation Insurance carrier and Policy number are::
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S IOG)
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 err
of Califomia. Date ! --
Applicant
NOTICE TO APPL]CAl�after rFSki�ng this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the tabor Coda 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.)
Lenders Name
Lenders Address
I certify that 1 have read this application and sate that the shove information is
COMM I agree to comply with all city and county ordinances and sate laws relating to
building convection, and hereby authorize representatives or this city to enterupnn the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT FRSTANDS AND WILL COMPLY WITHIL NON -POINT
SOURCE R TIONS.
kppacanuctlorwactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes 9No
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 QNu
1 have read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the bolding
does not rte
� O
Owncl Brtuthorimd a St IDate
4125 BLACKFORD AVE
(408)248-6600
PERMIT NO. .
07040151
PERMIT MSUE DATE
07/23/2007
SANITARY NO. CONTROL NO,
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
Job Description
SFDWL-2 STORY: 3402' GARAGE: 434'
Sq. Ft. Floor Area $753755 Valuation
36218069.W Number Occupancy Type
Required Inspections
Issued by:
Re -roofs
Type of Roof
Date /, 2.-3 -,.':�7
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