06030123BUILDING DIVISION
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BUILDING ADDRESS: V_L.VE1JA 11NiJUz)1tC1L"ib PERMIT NO. U13U-5U1G.S
11625 OAK SPRING CT
OWNER'
RUS2333 VEMIA CT. 03/22/2006
PHONE: SANITARY NO. CONTROL NO.
(858)530-0058
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70W) of Division 3 of the Business and//pprjppfessions Code, and my license is
n full force and c t. lG�
License Lie. #
Date Contractor
ARCHITECT'S DECLAR TION
I undcrstaod my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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 (550O1
❑ I, 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 We (Sec. 7044. 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 through his
own employees, provided that such improvements are not intended oroRered 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.).
❑ f, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's In-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
❑ 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:
❑ 1 have and will maintain a Certificate of Consent to self -insure for WorkersCompen-
sation, as provided for by Section 3100 of the Labor Code, for the performance of the
work for which this permit is issued.
'F61 1 have and will maintain Workers Compensation Insurance, as required by Section
6700 of the Labor Code, for the performance of the work for which this permit is issued.
My Wgrke enspd Insuran caricr and Policy number are:
Carri/
INSURANCE
(This section need not be completed if the permit Is for one hundred dollars (S IOO)
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 Workeri Compensation
Laws of California. 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 revoked.
CONSTRUCTION LENDING AGENCY
I 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.)
L.endces Name
Lenders Address
1 certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authome 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, costs and expenses which may in any way accrue against said City
In consequence of the granting of this permlt.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOI,jRCE R INS,
alc
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 &UD--
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
District7
❑Yes Nu
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505.25533 and 25534. I understand that if the building
does not currently have a tenant, that it is my responsibility to notify the Occupant of the
rcquircwcnL13,yhich be met prior lu i� a Certifrcare of Oats cy
Job Description
RETROFIT (7) WINDOWS AND (1) SP DOOR
NO WOOD CHANGES
Ft. Floor Area
3 69N 2YT4F! 0 0
Required Inspections
Issued by:
Re -roofs
Type of Roof
Occupancy Type
Date Y. 2-
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