06100050BUILDING DIVISION
BUILDING ADDRESS:
10038 ORANGE
OWNER'S NAME:
PHONE:
ARCHITECT/ENGINEER
10 0 LICENSED CONTRACTOR'S DECLARATION
iV t hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70f10) of Division 3 0! the Business and Professions Code, and my license is
in full force and effect.
i ? License Class Lic. N
L Date Contractor
iaq ARCHITECTS DECLARATION
Z I understand my plans shall be used as public records
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0 y Licensed Professional
rn 5 OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p O 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
Z <prior to its issuance, also requires the applicant for such permit to file a signed stat.ment
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 4
ti (commencing with Section 7000) of Division 3 of the Business and Profession9 Cod.) ur
it5 that is exempt therefrom and the basis for the alleged exemption. Any violation of
S Ion 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
n more than five hundred dollars (3500).
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1, 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 forsale (Sec. 7044. Business
and Professions Code: The Contractor's 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 oroffered forsale. 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.
ss owner of the property, am exclusively contracting with licensed contractors to
c wct the project (Sec. 7044. Business and Professions Code:) The Contractors Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
errse Law.
I am exempt n , j34 P C for this reason
Owner
I hereby affirm under penaty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
satlon, 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 Polity number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is foe one hundred dollars ($ 100)
or less.)
1 eerily that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any mannerso as to become subject to the Workers' 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
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 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 authorize representatives of this city to enter upon 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 UNDERSTANDS AND WILL COM Y WITH ALL NON -POINT
SOURCE
44-0
Signal pphcan on for Date
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)? //
C] Yes ®No
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?
❑Yesfu
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 building
does not currently have a tenant. that it is my responsibil ily to notify the occupant of the.
rcquiremens which must he meet p-riorrttoo issu