08060224I
CITY OF CUPERTINO r a
BUILDING DIVISION PERIVI[T � lC (� i1T � rp
BUILp fIw�vcc��wwDD RESS: - PERMfr Nil.
llbb� VINEYARD SPRING CT TBD — TO BE DETERMINED 08060224
SANITARY NO. CONTROL NO.
ARCHITEC71ENGTNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
i U I hereby affirm o P that I am licensed under provisions of Chapter 9(commencing
NNwith Section 7000)o[Division 3 of the Business and Professions Code,and my license is RMDL S KY L I T IN M S TRBTH, RE S I DNG W/HARD I PLANK S LC T
in full force and effect j n z License Class L1c.IFCEDARMI LL
F O Date Contractor
ARCHr=S DECLARATION
S 1 understand my plans shall be used as public records
)e F.
O F. Licensed Professional
y:1 OWNER-BUILDER DECLARATION
i hereby affirm that 1 am exempt from the Contractor's License Law for the
-0 0 following reason.(Section 7031-5,Business and Professions Code:Any city or county
awhich requires a permit to cnnstnect,alter,improve,demolish,or repair any structure:
-Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he Licensed pursuant to the provisions or the conllaclars license Law(Chapter 9 Sq.Ft,Floor Area Valuation
F- (commencing with Section 7000)of Division 3 or the Business and Professions Code)or $2 6 0 0 0
that he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031-5 by any applicant for a permit subjecu the applicant to a civil penalty of Number Occupancy Type
not more than five hundred dollars(S500)_ 36654011 .W
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the stru ium is not intended or offered for sale(Sec.7044,Business Required ired Inspections
and Professions Code:The Contractor' es License Law does not apply to an owner of Q
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 mla 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
u ).
'Las owner or the property,am exclusively contracting with licensed cnntr tors to
conswct the project(Sec-7044.Business and Professions Code:)The Contractoes Ld-
cease Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a conwactor(s)licensed pursoam to the Contractor's
L.leense Law.
❑I am exempt
DECLARATION
1 hereby affirm under penalty of perjury one of the following declamdons
❑1 hive and will malntain aCertiGute 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 Comper ation Insurance,as required by Section
3700 of the Labor Cade,for the performance of the work for which this permit is issued. '
My Worker's Compensation insurance carrier and Policy number arc:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COiv1PENSAIION INSURANCE
(This section reed not be completed if the perm it is for one hundred dollars(S 100)
of — - —
I unify that in the performance of the work for which this permit is issued,1 shall not
employ any person ro an mower m a tm a subject to the W ComP ti
I-a"of California • = lF"� /-�^r�
Applicant .
Certificate of ExImption.fou should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shag he deemed revoked Z — CONSTRUCTION LENDING AGENCY
her 1 hereby affirm that there is a construction lending agency for the performance of
(.Y,> the work for which this permit is issued(Sec.3097,Civ,C-)
W Q Lenders Name
a,z Lender's Address .
U 0 1 certify that 1 have read this application and state that the above information is
lL��.." conccL I agree to comply with all city and county ordinances and state laws relating to
C)p building construction,and hereby authmin representatives or this city to enter upon the
W shove-mentoned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertinoagaimt
Cn Iiabilities,judgments,costa and expemxs which may in arty way accrue against said City
V h- in eonscquencc or the grandng of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2
SOURCE
Re-roofs
Signature of ApplicanUConuact
HAZARDOUS MAT62ALS DfscLosoRE Type of Roof
Will the applicant or future building occupant store or handle haurdous material
as;deemed by the Cupettino Municipal Code,Chapter 9.12.and the Health and Safety
Code.Section 25532(a)?❑Yu All roofs shall be inspected prior to any roofing material being installed.
�o
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict7 \r
ElYes
1 have mad the hazardous materials requirements under Chapter 6.95 of the Cal ifor.
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does not currently haven a tenan4 that It is my responsibility to notify the occupant of the
requiremcnta w' rqust eto issuance or a CrniGcate car oc ry. Signature of Appl ieant Date
Z d All roof coverings to be Class'"or better
Owner or wthori7A agent Da