07070239�z
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CITY OF CUPERTINO
BUILDING DIVISION PE T
rMIT
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,App,(t
"'LITWEtRANGE AVE
P� NO.
TBD — TO BE DETERMINED
07070239
NO. CONTROL NO.
ARCHffECT/ENGINEER:
ADDITION 3 4 2 ' —NEW
BUILDINGPERMITu aD
BLDG MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am lied under previsions of Chapter 9 (commenting---
-
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fora and effect.
License Class LJe. N
'
Date Contractor
ARCHITECT'S DECLARATION
1 understand my plus 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 Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
APN Number
Occupancy
P cy T'Pe
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S300)
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the wont. and the souaure is not intended or offered for sale (Sec. 7044, Business
and Professions code: The Contractor's I license Law does not apply to an owner of
property who builds or improves therotm, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for We. If,
however. the building or improvement is sold within carte year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpm of
sale-)-
L as owner of the property. am exclusively contracting with licensed Contractors to
(cahstmict the project (Set. 7044. Business and Professions Code.) The Contractors U.
.
case Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such pmjects with a contractor(s) licensed pursuant to the Contractors
L.ieerue Law.
❑ I am exempt under Sea B & P C for this masott
^
Owner /d, Date 3 0, AV
WORKER'S COMVENSATION 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 Worker's Compen-
sadorL 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 Worker's Compensation trtmmsnce carrier and Policy number are:
- -
Carier. Policy No.:
CERTIFICATE OF FmfEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be Completed Ifthe permit is for one hundred donna ($100)
or less.)
1 certify that in the performarrce of the work for which this permit is issued. I shall not
amploy any person In any manner so as Co become subject to Ilse Workcrd Compensation
Laws of California. fare
Applicant '7'i_
NOTICE TO APPLICANT: If, after making 6is Certificate of Exemption, you should
become subject to the Works Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed rewkrA
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a oonstnrtfion lending agency for the performance of
dw work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I artify that I have read this application and sate that the ,boss information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building coosWttion, and hereby authorize representatives of this city to enter upon the
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 agahat said City
in of the granting this permit.y
APPLICANT
/
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.11. and the Health and Safely
Code, Section
sZSs3z(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes A1No
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 haz tious air contaminars as defined by the Bay Ara Air Quality Management
all new materials for inspection.
District?
El Yes No
I have read the hitmrdo s materials requirements under Chapter 6.95 of the Califor-
nia Fialth tier Safely Code, Sections 25505, 25533 and 25534. ]understand that if the building
does not cumnily have a Centre. that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a certificate or occupancy.
'VI1
Signature of Applicant Date
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All roof coverings to be Class' " or better
Owner Date
or authorized agent