08120002CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PERMIT ISSUE DATE
PHO SA AU;OCONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
COMM'L TI,CHG OUT LOBY O O O =
u O O LICENSED CONTRACTOR'S DECLARATION
m 1 hereby arm that I am licensed under provisions of Chapter 9 (commencing
ZO with Sectiaffirmon 7000) of Division 3 of the Business and Professions Code. and my license is
y in full font and effect Q %��
j r2 Z Ucensc CI Ct N o
C p Date Contractor
~ ARCHI ECrS DECLARATION
1 understand my plans shall be used as public records
7 o,U
1: O y Licensed Professional
5 OWNER -BUILDER DECLARATION
n
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p 0 following reason. (Section 7031.5. Business and Professions Code' Any city or county
m ri 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 Contractor's License Law (Chapter 9
F$ (commenting with Section 7000) of Division 3 of the Business and Profusion Code) or
i 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 dollar
❑ 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. 7044. Business
and Professions Code: The Contactors Licence Law does not apply to an owner of
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 proving that he did not build or improve for purpose of
salc.)_
❑ 1, as owner of the property, am exclusiwly contenting with licensed contractors to
constant 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 contacts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Caw.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I hsve and will maintain a CertiGOate of Consent to self -insure far Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 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 Worker's Compensation Insurance c2d Policy
number an::
dYce/PoIiieyNo.:DK 199 4W-q
ICrtrNDY A TOF MPTON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 100)
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 so as to become subject to the Worker Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
.J 0 forthwith comply with such provisions or this permit shall be deemed revoked.
ZCONSTRUCTION LENDING AGENCY
(-. I hereby affirm that there is a construction lending agency for the performance of
a the work for which this permit Is issued (Sec. 3097, Civ. C.)
W Q Lenders Name
�+ Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
W P correct- I agree to comply with all city and county ordinances and state laws relating to
0 U building construction• and hereby authorirr representatives of this city to enter upon the
W above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
,F'.� (A liabilities, judgments, costs and expenses which may many way accrue against said City
U Z in consequence of the granting of this permiL
r--r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR ULATIONS. (�
Ci�l
Signature of Applicant/Con or Dan
HAZARDOUS MATERIALS DISCLOSURE
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
Code. Section 25532(a)?
❑ Yes ANo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air QLWily Management
District?
❑ Yes Wu
I have read the hazardous maorials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the Occupant of the
require nis which�agcnt
of a Certificate of Oc%ancy. �Q.
_�/�i�r (J/Owner nx wthorveDao
DISPLY TO DIGTL DISPIJbibl)&WSption
Ft. Floor Area
APN Number
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date
__z_
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'n" or better