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CITY OF CUPERTINO
s
BUILDING DIVISION PE1
BUILDING ADDRESS:
PERMIT "0 4.0 5 0 0 2 9
22810 M
OWNER'S NAME:
PERMIT ISSUE DATE
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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
LiceneClassfull force dcffecL
2-STORY SFD (2542 SQ.FT. LIVING SPACE)
License Class Lie. M
Date Contractor
GARAGE 579 SQ.FT./REACTIVATED PERMIT #03060042
ARCHTI=S DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to cnnstruct, alter, improve, demolish, nr repair any structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors (itcnsc Law (Chapter 9
Sq. Ft. Floor Area
Vahigt" 0 0 0
(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
APN Number
Occupancy Type
Section 7031.5 by arry applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S51X) _
3 4 2 2 2 0 4 4. 0 0
❑ 1, as owner or the property, or my employers with wages as their sole compensation,
Required Inspections
will do the work, and the structure Isnot Intended orofferedforsale(Sec.7044.Business
and Professions Code: The Contractors License Law does not apply to an owner of
e q p
property who builds or improves thereon, and who doessuch 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
sale.).
C1 1, 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-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who conuacts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B &. P C for this reason
')
Owner" � - Date
WIJRK '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 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 Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section roved not be completed if the permit is foronc hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workcrs' Compensation
Laws of Califomia. Date
Applicant —
NOTICE TO APPLICANT: If, after making this Ccnifncatc of Exemption, you should
become subject to the Workers. Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constructinn lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
L.endces Name
Lenders Address
I certify that I have read this 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 authorim representatives of this city to enter upon the
above -mentioned property for inspection purposes
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, toss and expenses which may in any way accrue against said City
\
221
in of the granting of this permit.
A PLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
URGE REGULATIONS.
Type of Roof
4_4v) roofs
ignalu f pplicant/Conuacor D
HAZARDOUS MAT CLOSURE
Will the applicant or future building t store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Codc. Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑Ycs �Nu
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fissure building occupant use equipment Or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes AN.
I have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health S. 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 tht
requirements which must be met prier to issuance of a certificate of occupancy.
_ Signature of Applicant Date
All roof coverings to be Class "B" or better
wncr- r orircdagcnt Date