07060265CITY OF CUPERTINO
BUILDING DIVISION PERMITiTr!%
Y
SPRING CT
TBD - T060265
IT NO.BUILDINGADDg,ESSpLACER
NAME:
ISANITARY NO. CONTROL NO.
3z
Z CD
U4
ARCHITECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (eommcwing
With Section 7ODM of D' 'sion 3 of the Business and Professions Codt:, and my license is
in full force pd clTect.
Tj�''T]
C.icenae Lie. N
Date Contractor
ARCHrI'EC1-S DECLARA77 14
I understand 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. (Sccdon 7031.5, Business and Professions Code: Any city or county'
wych requires a permit to construct, ally —improve. demolish, or repair any structure
prior r 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 Contractor's License Law (Chapter 9
(commencing with Section 70Do) 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 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S-S(M
❑ 1, as owner of the property, or my employcna with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Cade: 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 employes, 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
I. as owner of the property, am exclusively contracting with licensed contractors to
!ipnstruct the project (Sec. 7044, Business and Professions Code:) The Comuactoes Li-
cense Law does not apply to in owner of property who builds or improves thereon. and,
who contracts for such projects with a contraaoR) liammil pursuant to the Conuactar's
License Law.
❑ Iaj
d c -- - — - ,B&PCf this
Owner
P.Lt4770N
by affirm mnder penalty of perjury one of the following declarations:[-I1Nd will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code: for the performance of the
work for which rids permit is issued.
❑ i have and will maintain Worker's Compensation insurance, as required by Section
370D of the Labor Code, for the performance of the work for wbich this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier, _ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 100)
or less.)
I ccnify that in a e w i�I permit is issocccL IQs�hall not
employ any pe n 1 y' yryvra�h .'
NOTICE TO APPll1CANIT'jf, afYcr`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 rcvokrA.
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_)
Lender's Name -
Lcnders 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 relaung 10
building construction. and hereby authorize representatives of this city to enter upon the
ahove-mentioned property for inspecuon purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Iiabiliues,judgments, costs and expenses which may in any way accrue against said City
in conaegumxc of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Appliesm/Conuaetor - Date
HAZARDOUS MATERIALS DISCLOSURE
Will fix applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Cbdc. Chapter 9.1Z and the Health and Safety
Code, Section 25532(s)? -
Yes
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arcs Air Quality Management
District?
❑ Yr {No
lhavereadthe and miquimunderChapter6.95oftreCalifo-
niaHcalth& 50 34.1undtnstind�building
does no
of c;.-.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
KITCHEN REMODEL-R G BUILDERS PD FOR BUS LIC.
Sq. Ft. Floor Area
36655002`�bT Number
Issued
Re -roofs
Type of Roof
valuation
$55675
Required Inspections
Occupancy'lype
Date
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
ail new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Date