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BUiLDING DIVISION PERMIT �►
BUILDING
DE
-
PERMIT
ANZA BLVD
TBD TO BE DETERMINED
07060090
OW NER'S NAME:
PERMIT ISSUE DATE
07/24/2007
PHONE:
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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
T.I. —REMODEL (E) TOILETS FOR ACCESS, MOVE (E)
in full License Cl and
fullClass Lic. N "1 C:7
PANEL BOXES.
Date '7.-7__g ,ems -Contactor r+
ARCHIfECIS DECIARA ON lN...
I understand my plans shall be used as public records
Licensed Professional .
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to Conswct, alter, improve, demolish, or repair any strycture
prior to its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the the Contractors Licenst Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions of
Section 7000) of Division 3 of the Business and Professions Code) or
$ 2 1 0 0 0
(commencing with
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 5 917 0 01 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (35001
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
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
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property who builds or improves thereon, and who does such wort himself or through his
own employers, 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.).
❑ L as owner of the property, am exclusively contracting with licensed contractors to
construct 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 contracts for such projects with a contractors) licensed pursuant to the Convector's
License Lew.
❑ 1 am exempt under Sec B & P C for ibis reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ 1 here and will maintain a Certificate of Consent to self -insure for Worker's Compenm
sarion, 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 Worker's 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 CompensatioIn-- Insurance carrier and Policy number am:
k_ _ 6CT-^^ V W v___�J (oO
Carrier: (f{w'" PolicyNo :
CERTIFICATE OF EXEMPTION FROM WORKERS ;p'j'(
^
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or Icss)
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 Workers' Compensation
Laws of California. Gate
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
forthwith comply with such provisions or this permit shall be deemed revoked.
I
'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is i construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
'
Lenders Name
,
Lenders Address
j 1 certify that 1 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
I above -mentioned property for inspection purposes.
(Wc) 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 COMPLY WITH ALL NON -POINT
Issued by: Date r e-C ,o7
TTONS.
"
Re -roofs
Type of Roof
Signature of Applicant/Contactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code. Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
If a roof is installed without first obtaining an inspection, I agree to remove .
Will the applicant or future building occupant use equipment or devices which
emit havardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes [I No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
L. that It is my responsibility to notify the occupant of the
requi must be t prior to issuance of a Certificate of Occ?upancy.
- • Z-
b
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or author'v�d agent Date