06100107BUILDING DIVISION PEiRNIJAhk "VN KIN�`u�1Y���
BUILDING ADDRESS: PERMIT NO.
CRAFTSMENS GUILD INC 06100107
OWNER'S NAME:
PHONE:
ARCHITECTIENGINEER:
o LICENSED CONTRACTOR'S DECLARATION
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
a in full force and
License Class Lk.
o Date Contractor
w ARCHITECTS DECLARATION
aI undersund my plans shall be used as public records
U
~ Licensed Professional
g OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License Law for the
0 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 suwure
y prior w its issuance, also requires the applicant for such permit to file a signal 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 arty applicant for a permit subjects the applicant to a coil penalty of
not more than five hundred dollars (S500).
❑ f, as owner of the property, or my employees with wages as their sale compe=tfon,
will do the work- and the structure is not intended or offered (or sale (Sec. 7044, Business
and Professions Code: The ConuwuWs License Law does not apply to an owner of
property who builds or improves thereon, and who does such wort hhmse f or through his
own employces, 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 w10 have the burden of proving that be did not build or improve for purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with G¢naed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Lf-
cense 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 Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations.
408
PERMIT ISSUE DATE
SANTTARY NO. CONTROL NO.
Job Description
BUILDING PERMIT INFO
ELECT PLUMB MECH
3 BATHROOMS, LAUNDRY - NON-STRUCTURAL
Sq. Ft. Floor Area
U
❑ I hive and will maintain a Cenificate of Consent to self-insum for WorkeesCompen-
sadon, as provided for by Section 3700 of the Labor Code, W the performer= 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 wort for which this permit is issued.
My Workers Com eats 'an Insu an=artier and Policy number ate: /j
Carrier.
CERTIMCA OF E)MAFrION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is fox one hundred dollars ($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 Workers' Compensation
Laws of California fate
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
2 forthwith comply with such provisions or this permit shall be deemed revoked.
0
14 CONSTRUCTION LENDING AGENCY
I hereby &Trm that there is a construction lending agency for the performance of
> the work for which this permit is issued (Sec. 3097, Civ. C.)
QLenders Namc
Z Lenders Address
Q 1 certify that I have read this application and state that the above information is
�—' correct. 1 a" to comply with all city and county ordinances and state laws relating to
Ubuilding construction, and hereby authorize representatives of this city to enter upon the
W above -mentioned property for inspection purposes.
GL (We) agree to save, indemnify and keep harmless the City of Cupcnino against
rA liabilities, judgmens, costs and expemaea which may in any way accrue against said City
2 in consequence of the granting of this permit.
�—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGU N
SignaWro of ApplianitConuactor Dare
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Munici Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes Z.
Will the applicant or futum building occupant use equipment or devices which
emit hazardous air contaminants as dcrand by the Bay Area Air Quality Managcmcnt
District? �K.�
❑ Yes 2
I have read the hazardous materials requirements under Chapter6,95 of the Califor-
nia HUM & Safety Code, Sections 255W, 25533 and 25534. I understand that if dx building
does not currently have a tenant my resporsihility to noufy the occupant of the
requirements which m tat rio wart= of a Cenificatc of Occupancy.
tb ralI
Owner rent Date
Issued by:
Re -roofs
Type of Roof
Required Inspections
Valuation
Type
Date 1p--( �)_ G�
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